 
<^e-c~
ijnmaHiA.Mrilti.Jl1.tl.
9^-^  / e^y
\j
BOLD.
//■'j'/
 
"*,■;   :&A

J&*l£j£*£>
DUE-HW^W«*»-Hl;




'T 24 J957



  16 jo
f i.
X * 3 
 
%
K
P
A  MANUAL
PATHOLOGICAL  ANATOMY.
 CARL ROKITANSKY, M.D.,

CURATOR OF THE IMPERIAL PATHOLOGICAL MUSEUM, AND PROFESSOR AT THE
        UNIVERSITY OF VIENNA, ETC.
      TRANSLATED FROM THE LAST GERMAN EDITION

                BY


WILLIAM EDWARD SWAINE, M.D.,   CHARLES HEWITT MOORE,

EDWARD SIEYEKING, M.D.,      GEORGE E. DAY, M.D., F.R.S.
FOUR VOLUMES IN TWO.
VOLS. I. II.
   PHILADELPHIA:

BLANCHARD  &  LEA.

        1855. 
ft V* V,  K./**f

c <
fv&iH-b-/
C. SHERMAN * SON, PRINTERS,
     19 St. James Street. 
A MANUAL
PATHOLOGICAL  ANATOMY.
 CAUL ROKITANSKY, M.D.,

CURATOR OF THE IMPERIAL PATHOLOGICAL MUSEUM, AND PROFESSOR AT THE
        UNIVERSITY OF VIENNA, ETC.
              VOLUME I.



GENERAL PATHOLOGICAL ANATOMY.




           TRANSLATED FROM THE GERMAN,


                   BY


     WILLIAM EDWARD SWAINE, M.D.,

           FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS;
        PHYSICIAN EXTRAORDINARY TO H. B. H. THE DUCHESS OF KENT.
    PHILADELPHIA:

BLANCHARD & LEA.

        18 55. 
y. 
AMERICAN  PUBLISHER'S  NOTICE.
  The numerous unsuccessful attempts which have been made to
present the following work in  an English translation, sufficiently
attest the very general estimation in which it is held, as well as the
difficulty of the undertaking.  The task having at last been executed
by the united labors of four gentlemen, each well qualified for the
portion intrusted to him, the American publishers take much plea-
sure in presenting to the profession of the United States, this great
store-house of pathological knowledge, in a convenient and accessible
form. The world-wide reputation of the author and of his work
render eulogy superfluous, while  the appearance of the translation
under the auspices of the Sydenham Society is a guarantee of its
fidelity.   Under these circumstances, and as subsequent papers
and researches of the author have been introduced in their appro-
priate places by the translators, it has not appeared to the publishers
that additions were necessary or desirable to such a work  or to such
an author, and they have consequently endeavored simply to secure
an accurate reprint.   For greater convenience of reading and refer-
ence, and to lessen the cost, the four volumes have been bound in
two, the paging, titles, &c, rendering each complete in itself.
  The volumes of the English Edition were not  published in their
regular sequence, Volume II. being issued first, and Volume I. last.
The reader is therefore referred to Dr. Sieveking's Preface to Volume
II., as well as to Dr. Swaine's Preface to Volume I., for some expla-
nation of the work, and of the manner and auspicesNmder which it
has appeared.
Philadelphia, August, 1855. 
/ 
EDITOR'S  PKEEACE
TO VOL. I.
  In issuing this portion of Rokitansky's " Pathological Anatomy,"
it is necessary to offer, on behalf of the  Council of the Sydenham
Society, some apology for the delay which has attended the com-
pletion of this important and voluminous work.  In his interest-
ing preface to  the second volume, Dr.  Sieveking  has recorded
one reason for the order in which  the  volumes  have been pub-
lished ; but he has not adverted to the main consideration by which
the Council was influenced, namely, the apparently  well-founded
hope that they might be enabled to present the Association with
the histological portion of the work in a new  and revised edition.
Encouraged from time to time in this hope  by the  author him-
self, the Council did not hesitate to defer, from year to year, the
publication of the first  volume, until they felt that it would be
improper to tax the patience of the members any further. The
new edition is still promised, but with  no  surer pledge  for its
early completion  than  heretofore!  The editor has, however,
availed himself to a considerable extent  of certain papers read by
the author before the Imperial Academy of Sciences at Vienna;
namely, On the Structure and  Growth  of Cyst and of Cancers,
&c.  He has even found  it not at all incompatible with the gene-
ral unity and concordance of the work to substitute, almost bodily,
the author's more recent essay on " Cyst and Alveolus," for the
comparatively  brief  and  imperfect article on the same subject in
the original.  These papers, there is reason to believe, contain the
principal results of the author's more  recent  investigations, and
therefore, in all probability, the  most important  of the additions
that might be  anticipated in a new edition.  The Council has
also  sanctioned  the introduction of two plates in illustration of
the newly added matter.
  At the conclusion of the work will be found a copious Index to
the four volumes collectively. To this each editor has contributed
his respective share, thus  offering to the English reader facilities
altogether wanting in the original work. 
Vlll
EDITOR'S  PREFACE.
  On the other hand the editor has felt the necessity of abridging
somewhat the author's general introduction, partly because, totally
unlike the general tendency of the work, it is of too  " transcen-
dental" a character either to suit the English language or to har-
monize with English ideas;  but more particularly  because it is
interwoven with a train of speculative reasoning upon the  relation
between power and matter, which  might,  in  this  countiy, very
possibly give rise to misinterpretation and rebuke.
  What Dr. Sieveking justly alleges of the general peculiarities of
Rokitansky's style, and of the difficulty of rendering his  writings
intelligible in English, is, by all who are conversant with the  origi-
nal, admitted to apply with especial force to the first volume. Upon
this ground  the editor ventures to urge his claim for a fair  measure
of indulgence on the reader's part.
  In conclusion, the editor, having been disappointed of a promised
autobiographical sketch, takes leave to subjoin a few extracts from
a short account of the career of this great pathologist, copied by a
friendly hand from the last edition [1854] of Brockhaus's " Conver-
sations Lexicon."
  " Charles  Rokitansky, the founder of  the  German  [it should
rather  have  been called Austrian] medico-anatomical school, was
born at Konigsgraetz, in Bohemia, was educated at the Gymnasium of
Leitneritz, and graduated, at Vienna, in 1828. Shortly afterwards he
was  appointed  Assistant in the pathologico-anatomical department
of the University, and, in 1834, Professor of Pathological Anatomy.
At the same time he was instituted Prosector at the General [united
Civil and Military] Hospital  at Vienna, and  also sole medico-legal
Anatomist for the examination of all doubtful cases of death through-
out that metropolis.
  " The immense fund of materials thus placed at his disposal [the
number of  corpses dissected by him is summed up at 30,000] was
almost entirely reserved for the elaboration of that grand  work
on pathological anatomy, which, in the consciousness of having
thoroughly mastered the subject, he gave to the world between  the
years 1842 and 1846; which has passed, unaltered, through  three
reimpressions;  and which, under the auspices  of the  Sydenham
Society, has been translated into the English language."
  " In 1849, Rokitansky was appointed Dean of the Medical Faculty,
and, in 1850, Rector of the University, of Vienna."
  York, January, 1855. 
AUTHOR'S  PREFACE.
  The appearance of this first volume brings the publication of my
" Pathological Anatomy" to a close.  As was the case with the earlier
volumes, the completion of this one has been  delayed by lack of
leisure, and especially by long and repeated attacks of illness.
  Whilst  engaged in working out  the design of this Pathological
Anatomy, I have throughout endeavored to act the part of a clinical
teacher;  and I believe  that, in so  doing, I have apprehended the
requirements of our day, and usefully disposed of the colossal
materials within my reach.
  The same self-reliance that characterized the commencement of
my pathologico-anatomical studies, has stood by me whilst engaged
in observing  and interpreting the facts of which the said materials
are  composed: for, each individual  discovery encouraged me more
and more  to  pin my faith upon Nature alone.  Still I have never
failed to watch and to appreciate the achievements of other men.
  The present work will at any rate tend to show, how thorough is
my  conviction  that  Pathological Anatomy  must constitute the
groundwork,  not alone  of all medical knowledge, but also of all
medical treatment;  nay, that it embraces  all  that medicine has to
offer of positive knowledge, or at least of what is fundamental to it.
Its domain will here, however, be found  more extended, and more
nearly approximated to the confines  of Pathological Chemistry than
has  generally been the case in pathologico-anatomical writings.
  Upon individual sections of the  work I must  confess to have
exercised a certain favoritism; and I have striven to cultivate and to
carry out some important general views, with a well-tested conviction 
X
author's preface.
of their truth.  Amongst these  views  I  may here single out for
exemplification the doctrine of a primitive diversity in blastemata,
as the only tenable basis for a humoral pathology.
  From a comparison of the  antecedently published volumes on
special pathological anatomy with the present  one, it will be seen
that the  former furnish  the groundwork of the views here pro-
pounded, and  that my convictions, upon the  whole, remain un-
changed.
                                         THE AUTHOR.
  Vienna, July, 1846. 
CONTENTS  OE  VOLUME  I.
Editor's Preface,    ....

Author's Preface,  ....

Introduction,  .....


                          CHAPTER I.

Anomalies in respect of the Number of Parts,


                          CHAPTER II.

Anomalies of Size,   ....
    Abnormal Magnitude,
    Hypertrophy,     ....
    Abnormal Diminutiveness,
    Atrophy,   .....


                          CHAPTER III.

Anomalies of Form,   ....


                          CHAPTER IV.

Anomalies of Position, ....


                          CHAPTER V.

Anomalies of Connection,


                          CHAPTER VI.
Anomalies of Color, 
Xll
CONTENTS.
CHAPTER VII.
Anomalies of Coxsistexce,
PAGE
 68
CHAPTER VIII.
Separations of Continuity,
69
CHAPTER IX.
Anomalies of Texture, .......	70
I. Organized New growths, ......	72
A. Of Organized New growths in general, .....	72
Blastema and its Metamorphoses with an especial reference to Fibrin,	78
Coagulated Fibrin, .......	82
Metamorphoses of Blastema, .....	86
Hyperemia, ........	91
Hemorrhage, .......	93
Anasmia, ........	98
Inflammation, Phlogosis, ......	98
Varieties of Inflammation, ......	105
Relation of the Inflammatory Process to Crasis, .	107
Exudation, ........	109
Pus, Ichor, ........	115
Issues of Inflammation, .......	124
Gangrene, Necrosis, .......	128
Characteristic of Inflammatory Textures and Diagnoses of Inflammation	
in the Dead subject, .......	132
Corollary, ........	133
Deposits, Metastasis (so called), .....	134
b. Organized New growths,	
Specially considered, .......	136
Areolar-tissue Formations, ......	137
Fibroid Texture, .......	138
Gluten yielding Fibroid Tumor, .....	141
Elastic Tissue and Texture of the Annulo-fibrous Membrane of Arteries,	142
Cartilaginous Growths, ......	143
Bone Formation, ••....	144
Growth of Bloodvessels, ......	149
Fat Formation. Fatty degeneration, .....	154
Fat Textures, ........	154
Normal Fat, ••••....	154
Abnormal Fat, ••••...	155
Free Fats, ••••....	156
Epidermidal and Hair Formations, .....	159
Pigment Formation, •••....	160
Colloid, ........	166
Cyst and Alveolus, •••-...	168
Sarcoma and Carcinoma, ......	189
*. Sarcomata, ........	190
 
CONTENTS.
xiii
       Cysto-sarcoma,    ....
       Appendix,     .....
  /8. Cancer.  Carcinoma,
       Colloid, Gelatinous Cancer.  Alveolar Cancer (C.
       Fibro-carcinoma (Simple Carcinoma),
       Medullary Carcinoma,
       Cancer Melanodes,
       Typhous Substance,
       Villous Cancer,   ....
       Epithelial Growths, Epithelial Cancer,
       Carcinoma Fasciculatum, .
       Cysto-carcinoma,
       Appendix,        ....
   Tubercle.  Tuberculosis,  .
     Albuminous Tubercle (Acute Tuberculosis),
     Albuminous crude Blastemata,
II. Unorganized New growths,
   a. Of Unorganized New growths in general,
   b. Of Unorganized New growths in particular,
     First Series,     ....
     Second Series,      ....
areolaire),
CHAPTER  X.
Anomalies of Contents,       ....
  a. Pneumatoses and Dropsy,     ....
  b. Foreign Bodies,    .....
  c. Parasites,       ......
     I. Parasite Plants (Epiphytes, Entophytes),
       1. Fungi within and upon the common Integument,
       2. Fungi upon Mucous Membranes,
     II. Parasite Animals (Siebold),
        1. Infusoria,   .....
        2. Insects,  ......
        3. Arachnida.  Acarina,
        4. Intestinal Worms.  Helminthes.  Entozoa,
             Nematoidea.  Round Worms.  Thread Worms,
             Trematoda.  Suction Worms,
             Cestoidea.  Tape Worms,
             Cystica.   Vesicular Worms,
       Spurious Parasites,      ....
     Blood Diseases.  Dyscrases,   ....
       1.  Fibrin-erases,        ....
          a.  Simple (Organizable, Fibrinogenous) Fibrin,
          b.  The Croupous Crasis (Piorry's Hsemitis),
               Croupous Crasis (a),
                          "   (0),    •
                          "   (?),-
          c. The Tubercle Crasis,
             Pyaemia.   Pus-blood,  ....
       2.  Venosity.  Albuminosis.   Hypinosis (Simon), 
xiv
CONTENTS.
  a. Plethora,
  b. The Typhus-crasis, .
  c. The Exanthematous Crasis,
  d. Hypinosis in Diseases of Nerves,
  e. The Drunkard's Dyscrasis,
  f. The Crasis of Acute Tuberculosis,
  g. Cancer Dyscrasis,
3. Hydraemia: Anaemia,
  a. The Serous Crasis.  Hydraemia,
  b. Anaemia,
4. Decomposition.   Putrid, Septic Crasis
Sepsis of the Blood,
Independent Anomalies of the Blood-Corpuscles, 
EXPLANATION  OF  THE  PLATES.
                              PLATES I. and  II.

  Figs. 1 and 4 represent proliferous cyst-formations from the cortical substance of the
kidney, as a sequel to Bright's disease.   The two figures, 1 and 4, illustrate well Roki-
tansky's history of proliferous cyst-development, and at  the same time what  he under-
stands by the often-occurring expression, "alveolar type or arrangement."
  In  fig. 1 we have the cyst in all  its phases,  a is a simple cyst, arising out of the
expansion of the elementary granule, first into the nucleus, from this into the cell, and
progressively into the cyst.   But it has  remained barren, and contains only a diaphan-
ous, viscid serum within a simple cyst-membrane,  b represents a parent-cyst, the early
history of which accords with that of the barren cyst; within it, however, new granules have
formed, and gradually become developed into vesicles or cysts containing other nuclei,
until  the parent-cyst has become replete with them, and from being spherical, they are
rendered  polyhedrical by mutual compression.  In an  adjoining parent-cyst, many of
the filial cysts have remained barren, others contain nuclei in the act of splitting,  c, c,
c, c, represent another form of development of the parent-cyst.  Here, again, the parent-
cyst has gone through the same phases, from the elementary granule upwards.  But, as
the cell dilates into the cyst, a granule forms centrally to the latter and expands into a
filial cyst, centrally to which a third granule opens out in the same manner;  and so on.
These intra-cystic cysts in their dilatation ultimately close upon the parent-cyst, forming
secondary, tertiary,  and ulterior layers,  to which an external, fibrous  layer is generally
added out of the surrounding blastema.  Or this fibrous coat accrues in the  alveolar
shape.  Fig. 1  affords several examples of this.  It is, however, better seen in
  Fig. 4.—a is the  fibrous  sheath in progress of development out of d, the elongated
and caudate nuclei coursing around the  parent-cyst or aggregation of parent-cysts.
They  eventually break up into the requisite fibres,  e is to represent the point-molecule,
within an amorphous blastema, out of which the nuclei (b) form. They are at first sphe-
rical,  afterwards elongated, and ultimately broken  into fibrillation.   This  constitutes
what the author designates as the " alveolar type or arrangement."  It is, however, still
better defined in
  Fig. 2, which represents cyst-formation in a medullary carcinoma.  From the carci-
nomatous framework a  bulb-like excrescence is thrown out, within  the extremity of
which a parent-cyst forms and becomes replete with filial cysts, each containing a cen-
tral nucleus.   This  parent-cyst surrounds itself with a broad marginal area of blastema,
within which elongated, caudate  nuclei course round the cyst in several tolerably regu-
lar circles or series—the rudiments of a dense fibrous envelope.  Such is the " alveolar
type," which applies to  the fibrous fabric of follicle walls as well  as to those of cyst-
formations.  (See " Cyst and Alveolus.")
  Fig. 3 represents a transverse section of a colloid cancer,   a is an older portion of
densely fibrillated fibro-membranous structure,   c  is a transverse section  of a more
recent fibro-membranous stroma;  b, a transverse  section of the colloid warp which
intertwines with the said fibro-membranous stroma.   (See p. 220.) 
xvi                EXPLANATION  OF  THE  PLATES.

  Fig. 8 represents the multilocular, fibro-membranous stroma of colloid cancer deprived
of its colloid contents.  (See p. 221.)
  Figs. 5,6, and 7, represent so many stages of the development of medullary carcinoma.
They are severally described  in the same order in which they are here numbered, at
pp. 220 and 221.
  Figs. 1, 2, and 4 are magnified by 90 diameters, the five remaining figures by 400
diameters.
   Several of the figures here given are embodied from Rokitansky's " Essays," in Mr.
Paget's admirable " Lectures on Surgical Pathology," vol. ii.
  Figs. 1, 2, and 4, are derived from Rokitansky's Essay  on " Cyst and Alveolus," read
before the Imperial Academy of Sciences, at Vienna, in 1849;  figs. 3 and 8 from  his
Essay on " Colloid Cancer," published in 1852; figs. 5, 6, and 7, from a thesis of his on
" Cancer-stromata," also published in 1852. 
 
PLATE I.
Fig. 1.
Fig 2.

Fis. 4.

""p^f^^lpi-
 
PLATE  II.
Fig. 5.
Fig. G.
I,    b
Fig. 7.
Fig. 8.
 
 
INTRODUCTION.
  Pathological  Anatomy may be said to be a modern science.   It is
indeed only of late years that it  has  assumed the dignity of an inde-
pendent science at all.
  Although, according to Pliny, dead  bodies were examined in Egypt
at the time of the Pharaohs, that is to say,  many  centuries before
Galen, with a view to detect  the  seats of disease; the result of those
researches has remained unrevealed to us.  Even upon Greek medicine
the  pathologico-anatomical  observations  made  by its founders  and
scholars have been without  material influence.   They  were indeed gra-
dually lost sight of in the medical schools, which arose out of the suc-
cessive systems of philosophy of a later period.
  Not until the commencement of the sixteenth century—the period of
the regeneration of anatomy—does the epoch begin of an occasional,
fragmentary,  indeterminate   study  of pathological  anatomy.   Still,
Eustachius, the rival of Vesalius, must have been deeply impressed with
its importance; for, towards the close  of his life he expresses his regret
that he had not rather bestowed upon pathological anatomy that time
and  attention  which he had  devoted to  physiological anatomy.  The
first who  dedicated  himself  in an  especial manner  to  pathological
anatomy was Antony Benivieni, who  wrote, at  Florence, " De abditis
morborum causis" (1507).    He  was  followed  by Mathieu-Reald  Co-
lumbus, the protector of Vesalius (1590), Volcher Coiter, a disciple of
Fallopius (1573),  Salius  Diversus (1584), Marcellus  Donatus (1588).
Johannes Schenkins collected the  observations made up to his time
(1584).  Johannes Wierus  (1569), Felix  Plater (1614), Fabricius Hil-
danus (1606), Tulpius (1672), Vesling (1664), Thomas  Bartholin (1654-
1675), Stalpaart van der Wiel (1677),  Daniel Sennert  (1676), Friedrich
Ruysch (1691), cultivated pathological anatomy  after their own fashion.
Their observations, although  partially of great  interest, often bear the
impress of superstition, and are disfigured by the fanciful way in which
they are interpreted.
  Since the time of  Harvey, the  discoverer  of  the  circulation, who, in
denominating our particular  science, medical  anatomy, showed how
fully he comprehended its import, various physicians have worked out
sundry  branches  of  pathology  anatomically.    Amongst them  are
Thomas Willis (1677) and  J. J. Wepfer (1658-1727).   Others,  as
Fernel (1679), F. Sylvius (1734),  Baillou (1735), have, in their com-
  VOL. I.                          2 
18
INTRODUCTION.
pendia of pathology, adopted pathological anatomy for their ground-
work.  Bonnet was, however, the first who compiled an ample repertory
on  this subject  (" Sepulchretum," 1679); and even this work unites to
the imperfections of earlier  observations the lack of a standard physio-
logical principle, and of a  definite  practical tendency.   The same
applies equally, if not more  forcibly, to Blankaard's " Anatomia prac-
tica" (1688).
  Above both these—above all that had been previously accomplished
—stands pre-eminent, Morgagni and his work, " De sedibus et causis
morborum" (1767).  Notwithstanding its defects, this  book remains  a
model  of industry  and perseverance, of method and  arrangement, of
breadth and perspicuity,  and, lastly, of originality, for all time.
  In the same  century, special investigations, not unworthy of record,
were made by J. Moritz Hofman, Walter, Albinus, Vater, Levret, W.
Hunter, Senac, Meckel, Bbhmer, Van Doeweren, Camper,  Bleuland,
and others.
  In a work  containing  a vast number of facts (" Historia  anatomico-
medica," 1768), the purpose attained by Morgagni, failed in Lieutaud's
hands,  through lack of detail, of analysis, of a practical generalization
of facts.   On the other  hand, Sandifort (" Observ.  anat. path., 1777)
merits, for the richness and solidity of his writings, to be classed along
with Morgagni.
  The  compendia published  in 1785, by C. T. Ludwig, and in 1796, by
Conradi,  and even  the greater work of Voigtl  (1804),  so marked by
literary industry and so serviceable withal, have not advanced science,
either by aptness of discrimination, by a judicious selection of matter,
nor  yet  by  any  remarkable progress  in  the  method of  anatomical
research.
  Mathew Baillie's anatomy of morbid structures (translated into Ger-
man by  Soemmering, in 1794)  is distinguished by greater  depth of
research into the fabric of organs, and both by its generalizing tendency
and its physiological  character.  These latter qualities are,  however,
still more  decidedly impressed  upon the  aphorisms  from pathological
anatomy published at Vienna, by Velter, in 1805.
  The most decided impulse was given to a right conception  and appli-
cation  of pathological  anatomy by Bichat  in  his  general  anatomy.
Bichat founded  upon the  latter an  especial physiology,  or rather,
blended the  two.   Pathologists, imitating this,  endeavored  to recon-
struct their science upon  an anatomical basis.
  France  was  the  country in which this attempt was made in the most
effectual  manner;  not that  it was exactly the  cradle  of pathological
anatomy, but that it was the land of all  others, in which men sought
and found in it a solid foundation for medical knowledge.   Such men
were, amongst others, Bayle, Corvisart, Laennec, Dupuytren,  Broussais,
Cruveilhier,  Rochoux,  Lallemand,  Riobe",  Andral,  Louis,  Gendrin,
Bouillaud,  Billard, Rayer.   It  is true  that one of  these   namely
Broussais,  disseminated  an  error from  which his pupils cannot yet
disentangle  themselves, an error  in which  Brunonianism seemed  once
more to be trying its strength upon  novel  ground.   On the other side
however, Laennec invented  and  carried out a method which  insures to 
INTRODUCTION.
19
him and to  his work the acknowledgment  and admiration of  future
ages.
   In England many have, up to our own day, worked in a similar spirit.
Amongst these, we may mention the names of Abernethy, Charles Bell,
Astley Cooper, Hodgson, Farre, Wardrop, Howship, Baron, Hodgkin,
Hope.
   In Italy, on the contrary, and in Germany—if we except the impulse
so decisively given in the same direction by the  ingenious Reil—patho-
logical anatomy has been upon the whole less cultivated, and has exer-
cised less influence  upon medicine.  Accordingly, Germany and  Italy
have but few men to place in parallel with those of France; few to add
to the names of Scarpa, Malacarne, Paletta—of  J. F. Meckel, Otto,
and (in industry and method, the essentially German) Lobstein.
   It was  reserved  for Germany, at the present  day, to  establish a
pathological  anatomy and a method of working it out, partly indepen-
dent, partly  framed according to the best  models of  France.  Under
the auspices of German universality and analysis, this renovated science,
emancipated  alike from  the systems of  a bygone age  and from a vain
eclecticism, has  begun to incorporate itself with pathology in a way
that promises both  durability  and brilliant progress, more especially in
its natural alliance with German physiology, and under a consistent and
rational standard of pathological chemistry.
   Classification.—Just as there  is a general and a special  anatomy,
physiology, pathology, so there must in like manner be a general  and a
special pathological  anatomy.   The former treats of general anomalies
of organization,  the latter of  the  special anomalies of individual tex-
tures and organs.
   All anomalies  of organization  involving any anatomical  change
manifest themselves as deviations in the quantity or quality of organic
creation, or else as a mechanical separation of continuity.  They are
reducible to irregular number [deficient or excessive formation], irre-
gular size, form,  position,  connection,  color,  consistence,  continuity,
texture, and  contents.  They relate  to the  physical properties of the
animal body and of its organs.  The chemical properties, although not
strictly pertaining to the field of anatomy, are too intimately connected
with the physical, to be  suffered to remain  in the background at the
present day.   The  animal fluids  bear a similar relation to anatomy.
Their anomalies will be taken into  account, so  far as  it may appear
needful, under  the appropriate heads.  Those of the sanguineous fluid
will, however,  demand a separate chapter.  This will come in at the
conclusion of the  general  anatomy, in  which a frequent  reference  to
them will have  previously demonstrated  the indispensable nature of the
inquiry,  as  a  sort of connecting  link between  general and  special
anatomy.   We shall thus  have to discuss, in ten separate chapters, the
anomalies of organization.   There  are, however, a few  general points
which require some previous explanation. 
20                       INTRODUCTION.
  I. The said anomalies, being simple  alterations  of the normal being
and of its parts, appear as abnormal conditions, excluding the idea of
an independent parasitic organism of disease.
  II. No formation  is incapable of becoming diseased in one or more
ways.   Several  anomalies coexisting in  an organ commonly stand to
each other in the relation of cause and effect.   Thus, deviations in tex-
ture very frequently determine  deviations in size,  in  form,—and these
again deviations in position.  Deviations in position give rise to anoma-
lies of volume and of texture.
  III. Pathological  anatomy, proximately concerned  with anomalies of
individual organs and systems—with local anomalies—has often reserved
for  it the task of revealing by  experiment and deduction the existence
of general disease, as  also  of  establishing the mutual  relations which
exist between the two.  The seat of general diseases may now be refer-
red, almost without exception, to the blood [the fluids].  They appear,
therefore, as  anomalies of admixture or crasis, either  primary or secon-
dary.
  IV.  This demonstration of general disease is indeed a step in advance
for  pathological  anatomy.  It threatens, however, to mislead us into the
error of  exclusive, transcendental, all-pervading humoralism—into  the
error of denying all local disease, by deducing the latter  in every in-
stance from a corresponding general affection,—not  but that many dis-
eases really are but the localization of a pre-existent general disease.
  V.  The existence  of purely  local—independent of general—disease,
from  the simplest inflammation—from blennorrhoea, to tubercle and
cancer, we look upon as grounded—
  (a.)  In the self-vitality of organs, and their  independent relations to
the external world.
  (b.) In the local influence of direct or reflected stimulation.   Either
directly, or through  the medium of  the nervous system, stimuli effect a
local modification in  the vital processes of absorption and secretion—in
the interchange of matter,—an anomalous reciprocity  between bloodves-
sels and their contents on the one side, and the parenchyma-engendering
products, abnormal both in quantity and in kind, on the other.
  Normal nutrition and secretion are no doubt mainly dependent upon
a normal crasis; but  they are also based upon the perfection of the spe-
cific vital action proper to individual parenchymata.   Anomalous secre-
tions often arise  out of influences which modify the vital action of the
parenchyma, and consequently its reciprocity with the unchanged gross
material, the blood: as, for  example, augmented  or  otherwise  altered
secretion of milk, produced by local irritation or by anomalous innerva-
tion, the effect of mental operations.  In like manner, local diseases are
but a consequence of qualitative and quantitative alienation of the tex-
tures and organs,—the formative material (the  blood), notwithstanding
its  reciprocity with the latter, not becoming sensibly contaminated.
  Influences, especially of a mechanical kind, are  often so strictly local
that it would be far-fetched to derive all local  disorder from a general
causal disease.   Even  the latter  would be but  secondary__a mere
transfer of the alienation locally produced. 
INTRODUCTION.                        21
  The existence of local diseases is further shown—
  (c.)  By direct evidence, where local  disease is established, of the ab-
sence of any disease of the blood crasis.
  [d.)  In the curableness by  topical  remedies—extirpation,  isolation,
&c.—of local diseases, without  their recurrence either on the same spot
or elsewhere.  The cure may even involve the simultaneous removal of
a general disease consequent upon the local one, this having possibly
acted as an anomalous instrument for  the elimination of certain elements
from the blood, exhausting it of certain essential constituents.

  VI.  Local disease extends beyond  its original seat in various ways:
  1. By contiguity.   The affection spreads to the immediate vicinity of
its original seat.   This extension is favored—
  (a.)  By  uniformity of structure.
  (b.)  By intensity of disease.
  (<?.)  By the nature of the malady.  Certain diseases, such as tubercu-
losis and cancer, in their extension, spare no texture, whilst the typhous
process upon the intestinal mucous membrane always finds an arresting
formation in the sub-mucous areolar tissue.
   2. The  disease  extends to  remote formations, both similar  and dis-
similar.  This mode of diffusion does not imply  concurrent general dis-
ease, but proceeds, according  to tolerably constant laws of  sympathy,
through the mediation of the nerves.  It is greatly promoted, however,
by a concurrent general disease, kindred in character with the  local,
causing it to increase, and multiplying the seats of the disease, as, for
instance, in inflammation.

  VII. The originally mere local is  enhanced into a general  disease of
the same nature, or gives rise to one of  different attributes.   The former
contingency may arise from the alienation of the peripheric nerves, pro-
ductive of  the local anomaly, being transmitted to the nervous instru-
ments  presiding over  the circulation,—in other words, to the nervous
centres, and  in particular to the spinal cord  and the ganglia.   Or else
the conversion assumes  the substantive form of infection, the  noxious
matter evolved by the original local disease, or its products, being re-
ceived into the circulation.  This last event occurs where  the products
of the local disease  exhaust  the blood of  certain ingredients, for in-
stance, of fibrine, of albumen, of serum, of salts.  To this class belong,
in like manner, the anomalies  occasioned by mechanical disproportion,
such as the venous diathesis,  cyanosis dependent upon disease of the
heart or lungs, &c.
  VIII. The presence  of  general  disease  may  be  the  more  safely
inferred:
  1.  The more widely extended is the local disease over several uniform
or dissimilar formations, and the greater its intensity.
  2.  The less the products of the local  process are conformable with the
character of the normal structures ;
  3.  The less the extent and nature of the local  disease, or of the  struc-
tures involved, however important in  the organism, suffice to account for
the general appearances during life and after death; 
22
INTRODUCTION.
  4. The more anomalous, compared with the alienation of the solids,
are the secretions and excretions ; and,
  5. The more the totality of the organism, in the  absence of actual
anatomical disturbances, seems cachectic and impaired.
  6. The more  marked is some  anomaly in the  circulating fluid, with
respect to the quantity or quality of its component parts.
  IX.  General disease engenders in  the most various organs  and tex-
tures, according to their innate general or individual  tendencies, either
spontaneously or by dint of some overpowering outward impulse, a local
affection which reflects the general disease in the peculiarity of its pro-
ducts.   The general disease becomes localized, and, so to speak, repre-
sented, in the topical  affection.
  X. A general disease not unfrequently finds in its localization a per-
petual  focus of derivation, with  seeming integrity of the organism in
other respects.  Recovery may, after a lengthened process, eventually
take place through the exhaustion of materials at the local vent.   Forced
extirpation, on the contrary,  or  insulation of the locality, generally
aggravates to a high degree the general disease, multiplying its points of
localization.
  XL  The disease has, even  anatomically speaking, its  stages  of inci-
piency, increment, acme, and decline.
  XII. The  terminations  of  disease  are, in like  manner,  subjects  for
anatomical research.
  1. The issue of local disease in health consists either in the perfect
re-establishment of  the normal condition,  or else in  partial recovery;
more or fewer important residua and  sequelae of the disease, not incom-
patible with a tolerably fair state of  health, remaining entailed.   Thus
the previously diseased organ may have lost substance, or  more or less
its natural texture ; or it may have suffered changes in form or in posi-
tion, or interruptions  of continuity.
  2. The  issue of  one  general disease  in another general  disease
[metaschematismus] is frequent.   Anatomical research proves,  and che-
mical analysis will still more clearly demonstrate, that it is far more fre-
quent  and varied than  would appear  from mere clinical observation.
This is taught in an especial manner in the mutual exclusion of different
morbid processes, which seem to succeed each other, when in full vigor,
sometimes almost by  a necessary  sequence.   Thus dropsy may succeed
to the  exhaustion of fibrine  and the  excretion of albumen, cancer to
tubercle, &c.
  3. Transition by so-called metastasis often becomes the subject of the
scalpel.   It comprises various conditions:
  (a.)  The localization of a general disease at an unusual spot. It has the
character of a vicarious or supplementary crisis.  Instances are afforded
in skin eruptions, and especially in the secondary typhous processes.
  (b.)  Topical processes  constituting the localization of  a metaschema-
tism, with which, as in the former instance, a general disease  concurs.
Such metastases occur more particularly in the sequel of  typhus, and in
the shape of inflammation, suppuration, gangrene, in both external and 
INTRODUCTION.
23
internal organs.  They represent the localization of a  general  disease
consecutive to the original typhous process.
   (c.) Local processes, with  the development of which the general dis-
ease  is essentially abated, or thoroughly exhausted and  extinguished.
They are frequent, and  deserve alone to be designated as  metastases,—
metastases in a  restricted  sense.  They are either  just sufficient vents
for the general  disease, and  are only cured when the latter is subdued;
or they heal spontaneously, the  dyscrasis having, through their agency,
become exhausted.
   (d.) When, owing to whatever cause, a local disease has been checked
in its  development, it subsides  only to reappear in another part, often
with augmented force, and with the supervention of a new general dis-
ease, or the aggravation of one already existent.
   4.  Issue in death.   Diseases  are mortal for the most part,
   (a.) Through exhaustion of power and of organic matter, tabescence,
loss of fluids.
   (5.) Through the  suspended  function of  organs essential  to  life;
through palsy;  through sudden and  extensive  displacements;  through
hypertrophy, atrophy, diseases of texture.
   (c.) Through vitiation of  the blood and  palsy of the nervous centres
arising out  of  the conflict  between  contaminated blood and nervous
medulla.
   XIII.  Where several diseases  coexist in  an individual, they are in
part primary, in part secondary and subordinate to, although  homolo-
gous with, the  former.  Again, they are partly sequelae and residua of
antecedent disease, as  in the case of atrophy of the brain  consequent
upon apoplexy,  upon  encephalitis.
   XIV. Very  dissimilar anomalies may coexist in one individual, as
mere local affections or complications.  Combination or  exclusion result
only in the case of heterogeneous  diseases  founded in or determining a
dyscrasis  : for example, cancer  and tubercle, organic heart disease and
tuberculosis.  The study  of these two relations opens a rich field of
promise for the furtherance of accuracy in diagnosis.
   XV. The import of a disease bears a direct ratio to the worth of the
organs attacked: take, for example, hypertrophy in different muscular
organs.
   XVI. With reference to the period during which anomalies originate,
we have to distinguish congenital,  or such  as have  become established
during intra-uterine life, and acquired, or  such as  have arisen during
extra-uterine life.   The former comprehend primitive anomalies.
  XVII.  Primitive anomalies comprise malformations.   These are de-
viations of the organism, or of an organ,  so intimately blended with its
primary development,  as  to occur  only  at  the   earliest  periods of
embryonic life, or  at any rate before that of mature foetal existence.
  Malformations, when  inconsiderable  and harmless to the individual,
are termed lusus naturce, variation, defect of formation, malformation ;
when more marked, deformity; when  excessive, misbirth, monstrosity,
monster. 
24
INTRODUCTION.
  Despite some progress made in this field of late years, the genesis of
malformation is still veiled in much obscurity.  . The opinions of modern
physiologists on this point may be collected under two  heads.  Accord-
ing to the one section, the  malformations are  referable to a  primitive
malformation of the germ. According to the other, to various influences
affecting the germ in the progress of development.
  The former opinion resolves  itself into that  of the ovists and that of
the spermatists.  Those  believed in the foreshadowing  of the malforma-
tion in the ovum;  these  regarded it as dependent upon the spermatozoa
as embryones.
  At this  day both theories are rejected as inapplicable to a vast num-
ber of malformations which unquestionably do originate during the de-
velopment  of the germ.  Still  the  malformation might be founded in
the nature of the ovum and of  the  sperma, although  neither of  these
constitutes the embryo.   The frequent recurrence of  the  same malfor-
mations out of the same parents, and the hereditary character of  these
anomalies,  render this not improbable.  We might further advert to the
nature of  certain malformations—inversions, duplicate formations, for
instance—in which the fusion of two  germs, and the bisection of a single
germ, during their development, are neither of  them quite conceivable.
  The second of the aforesaid propositions embraces several hypotheses.
  (a.) The oldest and  most popular attributes the malformation to a
sudden and  forcible  impression wrought upon the  mother (Verschen).
The question whether mental emotions  do influence the development of
the embryo must be answered in the affirmative.  Instances undoubtedly
have occurred of such maternal  impressions—fright more particularly—
when violent, giving  rise to malformations.   Seeing that many malfor-
mations  originate in  an arrest of development, and how frequently the
former bear a certain resemblance to various animals, it is just conceiv-
able that the development of the embryo may be so arrested  by mater-
nal  emotions as  accidentally to occasion a likeness between  the  object
that produced the impression and the resulting malformation.
  (b.) A second doctrine derives malformation from external mechanical
influences, such as a blow, a thrust, a fall, &c, suffered by the mother;
mechanical obstacles  to  the passage of the  ovum through the Fallopian
tubes, and to its  growth in the womb;  excess or deficiency of  liquor
amnii; restriction of space for  the foetus;  the formation of false mem-
branes within the cavity of the amnion, &c.   Although F. Meckel dis-
sents from this doctrine, we are not quite prepared to relinquish it our-
selves.
   (<?.) A third opinion assigns,  as the cause of  malformations, disease of
the foetus.
   Disease arrests the  development of foetal  formation with  respect to
growth,  shape, position, and texture of  particular organs, indirectly em-
barrassing the expansion of neighboring organs, or, it may be, causing
their destruction.  A  common  disease having this tendency is dropsy,
 as  preventive  of union or  closure,  and productive of disjunction or fis-
 sure.  Inflammation  and its consequences may be mentioned under the
 same head.
   The conditions of encephalocele,  of hemicephalus, of anencephalus, 
INTRODUCTION.
25
and of spina bifida, being obviously due to dropsy, are beyond the pale
of arrested formation.   Certain anomalies of the peritoneum and of its
viscera, formerly reckoned as  genuine  instances of arrested  formation,
have  been shown  by  Simpson in certain instances probably to result
from  foetal inflammation.   Some malformations of  the  heart, especially
defects  in its septa, we hold to be owing to foetal endocarditis, and to
consequent coarctation of the heart's orifices.
   The number of malformations, however, to which this doctrine fully
applies, is as yet  very small.   Amongst those which do not admit of
such an explanation are duplicate formations, and the great majority of
malformations designated by the term malposition.
   (d.) The  fourth  proposition—which  the countenance given to it by
Wolff, by Tiedemann, and especially by J. F. Meckel, has caused to be
the more generally received one—has formed the groundwork  for an
elaborate scientific inquiry into the subject, in especial connection with
the history of development.  This  sets forth that most malformations
represent certain stages of the  development of the embryo and of its or-
gans, at which stages formation has stopped short, or from which ulterior
development has ceased to follow the normal type.   The malformation is
therefore essentially an arrest of development.
   This theory of malformations is in a great measure correct.   Still it
does  not attempt to explain the cause of the arrest, which may be one
of those  already enumerated, be it concerned with  the germ,  with sick-
ening of the embryo, with mechanical influence, or with mental emotion.

   A  good classification of malformations is, owing to the difficulty of
establishing a principle of division generally applicable, as yet wanting.
If we attempt to classify them according to external form, we meet with
a  barrier in their  multiplicity.  Another obstacle consists in this, that
where several malformations  coexist in the  same individual,  they must
needs all be classified according  to the  one  most pronounced, and  the
designation be therefore  partially incorrect.  A classification founded
upon  the occasional causes is impracticable, since the same malformation
may originate  from various causes.  If we take for the basis external
form  and cause conjointly, the  classification becomes  bereft  of  logical
unity.
   It is desirable that we should  become acquainted with the  principles
upon which the more remarkable classifications hitherto propounded are
built.

   Passing over the older classifications, we should except that of Buffon,
as it forms the groundwork upon which almost  all the latter ones  are
modelled.  Buffon  divided malformations  into three classes:  1, malfor-
mation with excess; 2, with deficiency; 3,  with inversion or perverse
site.  To this classification we may subjoin  that of Blumenbach, under
the following four heads:  1, fabrica aliena; 2, situs mutatus ;  3, mon-
stra per excessum ;  4, monstra per defectum.   These were followed by
Meckel  in his division of malformations, as follows:  1, malformation
from deficient  plastic power; 2, from excess of plastic power;  3, from
deviation of the organs in respect to their natural form;  4,  malforma-
tions  characterized  by ambiguity of sex—hermaphroditism.  This  dis- 
26                       INTRODUCTION.
tinction of hermaphroditism from other malformations  constitutes the
great defect of Meckel's classification.
  Breschet  has,  in  his  classification, broken up Buffon's first class into
two, by separating duplicate formations from malformations  per exces-
sum.   The four orders of his classification are :  1, ageneses, devious for-
mations with  diminution of plastic power;  2, hypergeneses, with  aug-
mentation of plastic power; 3,  diplogeneses, devious formations with the
fusion of germs—duplicate formations; 4, heterogeneses, with alien cha-
racter of the product of generation.  The further division is  as follows :
  The first order, ageneses, breaks up into  four species.
  (a.) Agenesie,  absence—defective  development.   It is either partial,
        as in hemicephalie,  aprosopie, acephalie, apleurie;  or it is gene-
        ral, as in microsomatie (dwarfishness, cretinism).
  (b.) Diastematie, cleft formation at the median line.   It  is_ subdivided
        according as it  affects the head or  the  trunk, into diastemence-
        phalie, &c,  and diastematosternie,  &c.
   c.) Atresie.
   d.) Symphysie, coalition fusion.
  The second order, hypergenese, presents  two species, according as in-
dividual parts or  the entire  body are  concerned.   To the former species
belong macrocephalie, macroprosopie, &c.;  the latter consists of macro-
somatie (giant growth).
  The third order, diplogenese, is divisible  into external, through fusion
or adhesion,  as in diplocephalie, diplothoracie; and internal,  through
penetration (per penetrationem).
  The fourth  order has three species.
  (a.) Deviation  as to site,  either of  the  entire  organism [extra-uterine
        pregnancy]  or of individual  organs [ectopie].
  (b.) Deviation  as to number, polypaedie—the coexistence  in the uterus
        of several foetuses.
  (<?.) Deviation  as to color—leucopathie, cyanopathie, cirrhopathie.
  In this arrangement, the  distinction of dip-ogenesis from hypergenesis
is based upon  the unproved doctrine of the fusion of two germs constitut-
ing duplicate formation.  To the order, heterogenesis, are referred devi-
ations which ought not to be designated as malformations.
  One of the  best known classifications of  late years is that of the two
Geoffroy St. Hilaires, father and son, who handle malformations, accord-
ing to the natural method, under the term teratology (from  repaq,  mon-
strum).
  Malformations are  simple  and  complex—anomalies simples et com-
plexes.
  The simple—he'mite'ries—are either so-called variations,  lusus naturae,
where the anomaly is slight, causing  neither disturbance  of function nor
deformity, or  else defects of conformation,  malformations in  a restricted
sense, where,  however trifling  the anatomical deviation,  they impede or
preclude the exercise of one or more functions, or occasion deformity.
  They are divided into five classes, the anomaly being respectively con-
cerned with— 
INTRODUCTION.                       27
   1.  Volume, as regards size, both of the body generally, and of its in-
       dividual parts;
   2.  Form;
   3.  Structure and coloration;
   4.  Disposition;
   5.  Number and existence, that is absence or  presence of parts.

   These classes, according to extent and to degree—according to the
 kind  of  malformation,  are  divided  into orders, and these again distin-
 guished  according to the regions, systems, and organs involved.  Thus
 the first class comprises the four orders—general dwarfishness and gene-
 ral gigantism, partial gigantism and partial dwarfishness of proportions.
 The  fourth  class includes  the  five orders—displacement, preternatural
 union, preternatural connection, sept-formation, disjunction, &c.
   Complicated anomalies are classed in three subdivisions.
   1.  Heterotaxies [krepoq and to£X).  Anomalies important in an ana-
 tomical sense, but neither visible externally nor obstructive of any func-
 tion.   In mankind they comprise but one order, namely, lateral inversion
 of viscera  (inversion splanchnique).
   2.  Hermaphroditism.
   3.  Monstrosities.  Anomalies very considerable in degree, and con-
 sisting in  a faulty  anatomical  arrangement greatly deviating from the
 type  of  the  species, externally visible, and obstructive of one or more
 functions.
   These last  are divided  into three classes,—into simple, doub!fe,  and
 triple.   The  next division into orders  is arranged according to  physio-
 logical characters;  the subdivisions then following, according to tribes,
 families, and  species.   Thus, simple monstrosities resolve  themselves
 into three  orders:
   1.  Autosites, in which independent, progressive  development is possi-
       ble.  They are  capable of thriving for a shorter or longer period
       extra uterum.
   2.  Omphalosites,  in which  mere  passive nutrition is effected through
       the  placental circulation.   They are altogether very imperfect,
       more especially in relation to symmetry of the two sides of the
       body.
   3.  Parasites; shapeless masses, deficient even in an umbilical cord,
       adherent to the  sexual organs of the mother, and nourished at
       their cost.
   The first  order, autosites,  is divided  into four  tribes: the first tribe
 into two families;  ectromeliens, malformations with  deficiency  of  the
 extremities, with  the  varieties—phocomele,  hemimele, ectromele;  and
 symeliens,  fusion of members, with  the varieties—symele, uromele, sire-
 nomele.  The second tribe  has  the single  family celosomiens, prolapsus
 of viscera  and imperfect anterior closure, anterior fissure, eventeration,
 with the varieties—aspalasome, agenosome, cyllosome, schistosome, pleu-
 rosome, celosome.  The third tribe embraces the three families:  exence-
phaliens, imperfect  brain,  extra  cranium; pseudoencepTialiens, slender
 rudiments of brain,  with deficiency  of a large proportion  of the skull; 
28
INTRODUCTION.
and anencephaliens, complete absence of the brain and skull, with their
varieties.   The fourth tribe resolves itself into families: cyclocephaliens,
arrested formation and fusion of nose,  eyes, and upper jaw;  and otoce-
phalies, approximation and blending of the ears, with arrested develop-
ment of the base of the skull and brain, and concurrent malformation of
the apparatus of mastication—with their varieties.
   The  second order, omphalosites, has two tribes, with  three families
and their varieties.  The first tribe comprises the two families, para-
cephaliens,  rudimental head formation,  asymmetria  and  absence of
extremities and of many vegetative organs; and  acephaliens, complete
absence of head, with its  varieties.  The  second tribe  has  the single
family  of anidiens,  reduction of the entire organism  to a  membrana-
ceous  sac,  enclosing various soft  formations and  sundry  bloodvessel
ramifications.
   The third order, parasites, has the one  family zoomyliens, rudimental
embryo in  the abdomen, in the genitals, &c, with a kind of zoomyle.
   Double monstrosities are of two orders.

     1.  Double autositic monstrosities—fusion of two autosites.
     2.  Double  parasitic  monstrosities—union of an autosite with an
         omphalosite or parasite.

   The first order (double autositic) embraces three tribes.
   The first tribe subdivides into two families :  eusomphaliens, the union
of two  nearly perfect  organisms, each  possessed of a normal umbilicus
and umbilical cord, with several  varieties; and  monomphaliens,  the
union of two  organisms  having  one  umbilicus in common, also with
several varieties.
   The  second tribe includes the  two  families, sycephaliens, fusion of
head and trunk; and monocephaliens, two trunks, with one head; with
their varieties.
   The  third tribe contains  the  two families, sysomiens, single trunk,
with  double head; and  monosomiens,  mere vestiges of  duplicity about
the head ;  with their varieties.
   The second order  (double parasitic) comprehends three tribes.
   The  first  tribe has two  families :  heterotypiens, parasite and  autosite
united  about the umbilical region,  with varieties; and heteraliens, with
the  single species, epiconu, parasitic head upon  the  vertex (capitis) of
the autosite.
   The second tribe  blends the two families of polygnathiens, imperfect
head implanted in the maxillary apparatus of the individual; and poly-
meliens (fieXos, membrum), the parasite consisting solely of  extremities
and adjuncts;  with varieties.
   The  third tribe  has  but  one  family, the  endocymiens,  a parasite
enclosed within the autosite.
   The  triple monstrosities admit of the same distinction as  the double,
namely, into triple autositic and triple parasitic.
   The  doctrine of  the  two  Geoffroys, respecting  malformation,  fre-
quently errs in their having  neglected to adopt for its basis  the natural
laws of development.   The  system is even  not devoid of logical inac-
curacies, nor sufficiently compendious for practical use. 
INTRODUCTION.
29
  Another  well-known  German  classification is that of  Gurlt.   He
divides  malformations, generally, into the three classes of malformation
in one body, or simple monstrosities (monstra simplicia or unicorporea);
double or twin monstrosities (m.  duplicia  or bigemina); and  threefold
or trigeminal monstrosities (m.  triplicia or trigemina).
  The first  class is divided into six, and, including hermaphrodite forms,
into seven orders.
     1.  Malformation from deficiency of parts.
     2.  From minuteness of  parts.
     3.  From preternatural fissure.
     4.  From non-perforation  and  from fusion  of parts  (atresia  and
         symphysis).
     5.  From preternatural form and site.
     6.  From extraordinary  number of parts.
     7.  Hermaphrodites.
  The second class has two subdivisions.
         I.  Double malformations from coalition.
        II.  Double malformations from implantation.
   The first subdivision breaks  up into four orders.
     1.  Coalition without separation at either end of the  body.
     2.  Coalition with separation at the upper end.
     3.  Coalition with separation at the lower end.
     4.  Coalition with separation at both ends.
   In this  classification, as in  those of Breschet, double  formations are
 made distinct from malformations through excess of parts.
  The  most recent classification is that of Otto.  It approximates to
 those of Buffon, Blumenbach,  and Meckel.   It arrays  malformations in
 three classes.
  First class.—Monstra deficientia, furnishing three orders.
     1.  M.  perocephala, deficient in some  one portion of  the head, of
         which there are seven species.
     2.  M.  perocorma,  malformations with deficient vertebral column.
     3.  M.  peromela, deficient development of the extremities.
  Second  class.—Monstra  abundantia.   These  are divided  into  two
 orders.
     1.  M.  ex duobus coalita.
     2.  M.  luxuriantia.
   Third class.—Monstra sensu  strictiori  deformia.  It resolves itself
 into four orders.
     1.  M.  fissione deformia.
     2.  M.  coalitu singularum  partium  deformia.
     3.  M.  atresia" deformia.
     4.  M.  morbis manifeste deformia.
  To this   system  there is much to object:  for example, that  perverse
 site, that anomalies with respect to bloodvessels,  and certain herma- 
30
INTRODUCTION.
phrodite formations, have no place in it; that fissures and atresiae are
not  admitted as  monstra deficientia; that  monstra  abundantia  are
ascribed to coalition, &c.

  Lastly, Bischoff begins by showing that for a classification of malfor-
mations the anatomical  character alone can be made available, and that
the physiological principle is here altogether inapplicable.  Having then
pointed out the proper method of determining the anatomical character
—the diagnosis—of a malformation, he proceeds to build up the following
system, which, generally approximating to those of Buffon and Blumen-
bach, frequently differs  from both in detail, whilst by its rigid adherence
to anatomical principles, it seems to take the only admissible ground.
  First class.—Malformations deficient in  some  essential attribute of
       their kind.
  Second class.—Malformations possessing more than pertains to the
       standard of their kind.
   Third  class.—Malformations,  the organization of which does  not
       conform with the standard of their kind,  but without either the
       deficiency or the superfluity just referred  to.
  First class.—The  causes  to  which the  malformations, here under
consideration, are due, may be very various.   In many instances we are
justified in regarding them as products of imperfect conception, whether
the fault lie in imperfect formation  of the ovum or in anomalous quality
of the semen.  At this  day, however, so much in this assumption is still
hypothetical that we are compelled  to deal with it cautiously, addressing
ourselves, where it is possible, to other causes, more especially to inter-
rupted  evolution of  an organ out of its  germ, or to  its development
being impeded through  external influences,  such  as impressions wrought
upon the mother;  destruction of  the organ, in the progress of its deve-
lopment, through disease, particularly through dropsical  accumulation;
finally, destruction  of   an organ  through mechanical  influence—for
example, the amputation of a limb  by means of the umbilical cord or a
pseudomembranous formation within the ovum, &c.
  This class comprises the following orders :
     1. Deficiencies in a stricter sense.
     2. Malformation from diminutiveness of parts.
     3. Malformation from coalition (symphysis).
     4. Atresiae.
     5. Cleft-formation.
   Second class.—Here we meet with a regular  progression, from the
supernumerary bone  or  finger up to the development of two perfect indi-
viduals, united only at one part.  The series of this progression is so
graduated and so  complete, that Bischoff regarded it as impracticable,
even on anatomical grounds, to make  any break  in the respective for-
mations, although  Breschet and Gurlt have done this by distinguishing
formations  possessing single  supernumerary parts with a single  head
and trunk, from those in which these latter are twofold,  and which they
denominate twin-malformations.    This  distinction  is,  however based
upon a physiological principle in itself objectionable.  It is only to the 
INTRODUCTION.
31
former species of malformation  that  we assign excess of plastic vigor
as the source of the  supernumerary parts; whilst true twin-formations
are referred to the fusion or coalition of double primitive germs, imply-
ing deficiency of plastic vigor, inasmuch  as each germ  individually
must be imperfectly developed.
  This class comprises the following orders:
    1. Malformations from  superfluity of  single parts,  with a single
         head and trunk.
    2. Twin malformations with double head and trunk.
    3. Double malformations from implantation.
    4. Triple malformations.

   Third class.—Its  defect is that its characteristics are principally of a
negative  kind.
  The objects  comprised in this class  being  very numerous, their pro-
bable sources are  in a  corresponding  degree various.   For several
formations no other cause can be assigned  than an anomaly of plastic
activity originating in some primitive  configuration of the germ; in a
few other instances disease may be assumed as the cause; the majority,
however, will be explicable on the ground of arrest of  development.
   This class contains the following orders:
     1.  Change  in the position of organs.
     2. Deviations in the form of organs.
     3. Deviations in the origin  and the disposition of the arteries and
         veins.
    4. Hermaphrodites.

  As, according to our plan, all malformations will be considered under
heads corresponding  with the classes and orders of the  above system,
and as we shall  also  follow  Bischoff  in our physiological  notice of the
species,  an  occasional reference to this system will,  for the present,
obviate the necessity for  a further enumeration of  the  species belonging
to each order.
  On the other hand, we have here to notice, in a  general way, the laws
which nature observes in the production of malformations, so far as a
general working out of this subject has  revealed them to us.
  1. The worst malformation is never so anomalous as not to bear the
general  characters of animal  life, and  the external semblance  of the
particular class  of animals  to which it belongs.   Even  an  individual
organ never departs from its normal character so completely that, amid
even the  greatest disfigurement,  this character should not  be cognizable.
  2. Deviations from the normal are, then,  confined within certain
limits, and  this applies in an especial manner to anomalies of position.
Although that which should lie on the right may appear on the left,
and the  converse—the abdominal organs occupy the thorax, and  the
thoracic the abdomen—the brain has never yet been found in the chest
or abdomen, nor the  kidneys  within the skull.  The natural history of
development reveals  the cause,—different  organs and systems being
developed out of different layers of the germ; those  pertaining to the
same layer may indeed err  as to their  locality, but in no instance will 
32
INTRODUCTION.
an organ pertaining to the animal, become evolved out of the vegetative
layer of the germ, nor the converse.  Fleischmann calls this the law of
localities (lex topicorum).
  3. To this we may add, that certain conjunctions between organs,  for
example, the  aorta  and the intestinal canal forming  a single  tube in
common, never occur; but that, as a rule, homogeneous or kindred parts
alone unite, a law termed by Fleischmann the law of individuality (lex
proprietatis).
  4. The excessive  development of  one  part determines the imperfect,
retarded  development of another, and the  converse.   Meckel having
laid it down as the  next thing to a law, that a preponderance of one
organ is  associated with the retarded growth of  another, Geoffroy  St.
Hilaire  has invested this  law—as the law of compensation  (loi  de
balancement)—with the most  ample  significance  and  extension.  The
said law has in reality sundry  facts  for its foundation; it is  alleged, in
particular, that individuals  having  on one  hand  or one foot a super-
numerary finger or toe, are  often found  wanting in a  finger or toe on
the other foot  or hand.   A foetus  described by Neumann had on  the
left foot only the great  toe, but, on  the right, eight  toes,  the eighth
being cleft.  Segala's foetus had no  thumb to  the left  hand—to  the
right, two; it  had  on one side eleven  ribs  only, but  thirteen on  the
other.  In  cases  where more  or fewer important  parts are  wanting or
imperfectly developed, we often find supernumerary fingers and toes ; fov
example, in anencephalia,  cyclopia, spina bifida, hare-lip, cleft abdo-
minal parietes, &c.   In the siren-malformation  there  is, according to
Meckel,  always an  excessive  number of  vertebrae and  of ribs.   In
acephali, deficient in heart and liver, the kidneys are asserted by Elben
to be preternaturally developed.   On the  other  hand, in the double
formation of individual  parts, others  are frequently  imperfect: thus,
bitruncate  malformations are  frequently acephali, whilst  the bicepha-
lous have often spina bifida;  and  in either case sundry other organs
besides have suffered an arrest of development,  being deficient in abdo-
minal parietes, the intestinal canal  being imperfect, the urethra imper-
forate, or cloacal malformation present.   Meckel has even  made  this
law apply to different children of the same  parents:  one girl  had on
each hand a supernumerary finger, her sister had two fingers  wanting to
one hand.
  Meckel, rightly, we think, rejects the assumption of a law  of compen-
sation, where compensation is so far from general, and admits only that
malformations  are  often influenced  by a  law common to  organized
bodies.
  5. Not every organ or part is in  an equal measure obnoxious to mal-
formation.   According to Meckel it is far more rare in organs supplied
by cerebro-spinal nerves (muscles, larynx, lungs), than  in those supplied
by the sympathetic (the digestive,  urinary, generative).  The vascular
system is, however,  most liable of all.
  6. Certain  malformations affect certain  organs.   Thus   it  is  an
admitted fact that  formations resulting from the vegetative and  the
vascular layer of the germ  seldom multiply, compared  with those which
result from the animal layer.  Instances of multiplied heart, lungs  in- 
INTRODUCTION.
33
testinal canal, uropoietic and generative  organs, are far more rare than
of multiplied head, organs of sense, extremities, &c.
   7. Whilst  certain malformations are  about  equally frequent in both
halves of the  body, certain others affect by preference  the one or  the
other side of  the  upper or the nether  half of the body.   Where  the
vertebral  artery originates immediately from the  aorta, "this,"  ob-
serves Meckel,  " happens invariably on the left  side."  Cleft lip and
cleft palate are commonly found on the right side.  Malformations from
superfluity are much more frequent in the upper than in the nether half
of the body.   Thus, bicephalous monsters with a single trunk are more
frequent than monocephalous with double trunk;  supernumerary fingers
than supernumerary toes.  In like manner, anomalous bloodvessels  are
more common in the superior extremities than in the inferior.
   8. Female malformations  are, by all  accounts, much  more frequent
than male.  A reason for this cannot at  present be assigned.
   Of the hereditary nature of malformations, and their repetition in
children of the same parents, Meckel has collected numerous examples.
The entail  is transmitted equally through  the male and through  the
female line.  Meckel adduces an  instance of a man with six fingers to
each hand and six toes to each foot transmitting the same malformation
to his eldest  son, whose  three sons again were born with precisely  the
same redundant organization.
   Various and manifold as are the forms of monstrosity, some of them
recur with  such uniformity  of type, as  to  constitute  a regular series.
This applies to  every organ,  each  being  especially liable to some parti-
cular kind of malformation.   This  circumstance is of great importance in
summing  up the causes of malformations.   It  indicates that,  in  the
majority, not an extrinsic, accidental cause prevails, but an intrinsic one,
inherent in the laws of germination and development.
   With the  aforesaid laws, derived more immediately from malforma-
tions, a mistaken  attempt has been made to couple two other special
laws:
   1. The first being that of Serres, according to whom the development
of an organ altogether  depends  upon  the  development  of the blood-
vessels, and especially of the arteries.   Conformably herewith, imperfect
development, or the  absence, or again the excess of an organ  or part,
would be a consequence of the insufficiency,  or  the absence, or again of
the preternatural development of the supplying artery.   But even were
the fact altogether true, the cause  of the defective or excessive develop-
ment of the artery would still remain to be accounted for.   The rela-
tion, therefore, not of dependence, but merely of correspondence between
the degree of development of the  malformed organ and of its supplying
vessels,  would be proved, as the rule, and even this subject to occasional
exceptions.  Bischoff, however,  regards  as decisive the direct  observa-
tion that, in their rudiments,  organs are immediately evolved out of  the
germ, previously to their being furnished from  bloodvessels; the consti-
tuting  cells  subsequently becoming metamorphosed  in such wise, that,
out of one portion bloodvessels and blood, out of another the other
(secondary) elements of the organ are derived.
   2. According to the second law, the  nerves are substituted  for  the
    VOL. I.                        3 
34
INTRODUCTION.
bloodvessels,  as the media of development.  Tiedemann has shown that,
with the absence of certain nerves is coupled the absence of their depen-
dent organs; that in all monstrosities with excess, a corresponding rela-
tion is demonstrable in the nervous system; and, again, that in malfor-
mations with  coalition of organs, the  fashion  of this union is exactly
imitated by the supporting nerves.  On  the  other hand,  the natural
history of development has shown that the central parts of the nervous
system  constitute  the first vestiges of the embryo,  being thrown  out
cognizably as  such by the germ.   Upon  such grounds, the opinion  has
been formed that,  like the normal, so  also the anomalous development
of the different organs of the embryo is dependent upon the normal or
anomalous  development of the nervous system.   Against this  view  the
objection hinted at in the last paragraph might again  apply.
   XVIII.  The disposition  to different  diseases varies according to age,
sex, climate, &c.
   Thus, aneurism belongs chiefly to manhood and advanced age, rickets
exclusively to  childhood;  the foetus labors under  anomalies  proper to
primary  development alone—namely, malformations.   In childhood
tuberculosis attacks, preferably to all other parts, the lymphatic glands,
the brain;  at and  beyond the age of puberty, the  lungs.   The female
sex greatly favors  the occurrence, in the  sexual system, of cystoids, of
cystosarcoma,  of the majority of cancerous growths.   Under certain
climatic relations, tuberculosis is rare,—intermittent fever, hypertrophy
of the spleen, frequent; under the tropics the ossification of arteries is
said to be extremely rare.   Again, particular regions and  parts of  the
body manifest different dispositions with respect to the frequency of con-
genital or acquired anomalies.  Thus, Portal pronounces apoplexy to be
more frequent in the right corpus striatum than in the left,—pneumonia
is more common in the right  lung than in the left.  The arteries of  the
inferior extremities  are infinitely more  obnoxious than those of  the
superior to ossification and to spontaneous aneurism; the veins of  the
lower half of the body are almost exclusively subject to varix.   Malfor-
mation from excess appears more frequent in the upper half of the body,
malformation from coalition more frequent in the lower half; variations
in the  course of bloodvessels are more rare in the inferior extremities
than in the superior. 
PATHOLOGICAL  ANATOMY.
                         CHAPTER I.

       ANOMALIES IN RESPECT OP THE NUMBER OF PARTS.

  Tiiese consist in diminution or augmentation of the normal number
of organic parts.  It is not rare for both to be found united in one indi-
vidual, one part presenting a deficiency,  another, in virtue of the law of
compensation, an excess of formation.  Thus, monstrosities, in which
otherwise  deficiency predominates, will exhibit a  superfluous  finger or
toe ; double twin malformations, on the  contrary,  deficiency in  various
parts.
  Deficiency or  absence of individual parts, or diminished number of
plural organs, are frequent,—for example, the absence of entire extre-
mities, of individual fingers and toes ; amongst the  viscera, of one of the
kidneys.   It is either congenital or acquired.   In  the former case it in-
cludes  malformations  with deficiency, in  a  stricter sense.   There is
scarcely any part that has not been found wanting, without detriment
to the entirety of the rest of the body.  In this respect, however, certain
relations or  sympathy may not be overlooked, by virtue of which the
absence of one  part is paired with that of  another  part.  Thus, in
acephali the heart is almost always absent, very commonly,  too,  the
entire thoracic viscera, together with  the liver, the spleen, the pancreas,
—an example of compliance with rule perfectly inexplicable; for neither
can development from an  identical germ, nor functional dependence of
the  organs here  be argued.   Occasionally so many parts are absent at
once, that nothing is born save a head,  a  single extremity, or a shape-
less mass.   The absence of parts is very often, though by no means inva-
riably,  due to arrest of development.
  The principal  kinds of  malformation that pertain hither are the fol-
lowing  (Geoffroy St. Hilaire,  Gurlt, Bischoff):
  1. Amorphus, anideus.   A shapeless mass consisting of cutis, areolar
tissue, fat, and a few bones;  is never found but in association  with a
perfect twin.  It probably results from  an early destruction  of  the
germ.
  2. Acephalus.  The head alone may be wanting, or with it more or
less of  the trunk, so that,  in fact, nothing may be present save a pelvis
with the inferior extremities,  or with one  of these only.  It is for the
most part associated with a twin.  Even though  the trunk be present, 
36
ANOMALIES IN RESPECT OF
the heart is usually absent;  the respiratory organs  probably always;
liver, spleen, and pancreas commonly; stomach and intestinal canal are
generally  very defective;  the  uropoietic  and  generative  organs  are
mostly present, though incomplete.   It is in some instances perhaps de-
ducible from injury to or destruction of the germ, or from the distur-
bance occasioned by a twin.
   3.  Pseudacephalus, paracephalus.   Rudiment of head, with the rest
of the body either entire or defective.  These are  sometimes twin cases,
and are for the most part the consequence of hydrocephalus.
   4.  Aprosopus.  The  face, and especially the eyes, nose, and  mouth,
wanting.   The skull is  diminutive, and  exhibits the ears coalescing,
either in front or above.  The brain is  always  very  defective.  The
pharynx terminates, superiorly, in a caecal sac.   Here again, probably,
destruction—splitting of the medullary tube, as also of the dorsal plates,
at their anterior part, takes place at an early period.  Hence the non-
development of the anterior brain-cell with eyes  and nose, and  in like
manner the superior arches of the cranial vertebrae, of the  parietal and
of the frontal vertebrae, and the consequent inclining towards each other
of the temporal bones for the closure of the vertebrae.  Hence, probably,
also,  the  non-development of the  anterior visceral  arches, involving
absence of the  inferior maxilla and of the facial bones, with anterior
junction of the external  ears, which  emanate from the second and third
visceral arches.
   5.  Microcephalus.    Diminutive,  incomplete  head;  similar  to  the
foregoing,  except that the  inferior jaw is present, proving the develop-
ment of the first visceral arch.
   6.  Anophthalmus.  Absence of both eyes or of one eye  only.  Eye-
lids and  lachrymal organs  are present,  although  often   defective—
coalescent.   Perhaps" for the  most  part  dependent  upon  dropsical
destruction of the eye-vesicles, rudiments of the optic nerves being com-
monly discoverable.
   7.  Absence of the eyelids ;  an arrest of formation,  these organs being
of later development.
   8.  Absence of iris ; in like manner, an arrest of formation.
   9.  Anotus.  Absence of the external ear,—deficient development of
the external portion of the first visceral groove.
   10. Brachyrhynchus.  Shortness of nasal prominence,  owing to de-
ficiency of intermedial jawbones.
   11. Acormus.  One  rudimental head with  a regular  twin, or with a
triple birth.   Most probably  due to mechanical  hindrance to develop-
ment, and to destruction occasioned by the other foetus or foetuses.
   12. Oligospondylus.   Absence of  vertebrae  or of semi-vertebrae, is
owing either to an anomaly of original germinal development, or else to
the coalescing of two or more vertebrae or semi-vertebrae.
   13. Anaedceus.   Absence  of the entire  generative apparatus, or of
the external organs of  generation only; very rare  as an  independent
malformation, where  the individual is otherwise  normally  formed.  It
is  an arrest of development, the said parts  not being evolved out of
the germ.
   14. Peromelus and micromelus.   The limbs  are wanting or maimed. 
THE  NUMBER  OF  PARTS.
37
It is frequently an  arrest  of  development;  it may, however,  result
from mechanical  influence,—from the  severing of  members through
strangulation.
   15.  Phocomelus.   Monstrosity with  phocal extremities, the  hands
issuing directly from  the shoulders, the feet from the  pelvis, whilst the
intervening parts  are either wanting or merely rudimental.   It is  an
arrest of development often dependent upon hydrocephalus  or spina
bifida.
   16,  Parosomus.  Various  deformities caused by the absence  of  in-
dividual parts.
   17.  Absence of various individual organs of the thorax or abdomen,
of a lung, the  liver,  the spleen, the stomach or its blind sac, a portion
of intestine, &c.   It  is either an arrest  of development or the result of
morbid destruction.
   A particular kind of diminution of number consists in  the symphysis
or fusion  of kindred formations; fusion  of  two fingers,  toes,  ribs,
vertebrae,  of the  inferior extremities,  of  the kidneys, obliteration  of
the  uterus.  A deficiency of various grades  is included  under cleft-
formations.
   The acquired absence of particular parts is  the  result of mechanical
influence  or of disorganization.   To  the former  kind belongs  maiming
by accident or design; for  example, amputation,  extirpation, and the
like, which sometimes greatly resemble  certain congenital defects.  To
the  latter kind is to be referred the wasting of various organs;  for in-
stance, from spontaneous, primitive atrophy, from that consequent upon
inflammation, from destructive suppuration or gangrene.
   Preternaturally augmented number of parts is very  frequent, and
commonly congenital.  It occurs in  every variety of grade, from the
duplication of individual diminutive parts to that of the body almost in
its totality.  These various  degrees constitute a series, the gradations
of which are so regular, that  it would appear forced to divide malforma-
tions of this class into such as with a single head and trunk present du-
plicates of individual parts, and into such as at the same time possess
double or triple head and trunk.   Nor  does  such a distinction  derive
much support from the assumption that the former  are due to an excess
of plastic activity, the latter to  the primordial existence and the fusion
of twofold germs.
  Bischoff (with Winslow, Haller, Meckel) opposes the following weighty
arguments to this distinction, as also to the assumption of twofold germs
and their fusion (Lemery, Breschet, Gurlt, Chaussier, and Adelon).
  1. The malformations of this class, from the supernumerary finger  or
toe up to the  development of two perfect embryos united only at one
point, constitute so complete  and uninterrupted a  series, that  it would
be in the highest degree forced to assign for the one  and for the  other
opposite  causes, namely, excess of formative activity, and again fusion
with deficiency  of plastic power.   Still no one can hold a supernumerary
finger or toe  to be due to the fusion of two embryos.
  2. In twin malformations, none but the same organs, systems, or parts,
whether internal or external,  ever coalesce.  It is invariably thorax with
thorax,  abdomen  with abdomen, head with head,  breech with breech. 
38
ANOMALIES IN  RESPECT OF
Again, brain is ever found coherent with brain, bloodvessels with blood-
vessels, intestine with intestine,  &c;  never trachea with  oesophagus,
nerves with bloodvessels, and the like.   This is a fact, the constancy of
which precludes its explanation on the ground of accidental fusion from
external causes.
  3. Twin malformations manifest,  for  the most  part,  a  change not
limited to  the  parts immediately  united, but pervading the entire  or-
ganism.  Such a change could hardly be brought  about by accidental
fusion.
  4. Twin malformations always  recur  with great uniformity of cha-
racter.  Are external causes likely  always  to  combine after the  same
fashion ?
  5. Again, twin malformations  often occur out of the  same mother,
and the tendency to  them  is hereditary.   There  is neither proof nor
probability of an abiding external cause,—for instance, in the maternal
organs of generation.
  6. At no period of  development is a mechanical fusion of the ova and
embryos probable;  indeed, our present knowledge respecting the nature
and earliest development of the ovum renders such  fusion highly impro-
bable.   The pellucid zone or yelk-bag is in the highest degree unfitted
for it;  nor is it at  all possible to press two ovula against each other in
such wise as to occasion the fusion of their yelks, of their  germinal vesi-
cles, or of the zonae pellucidae of the  latter.   In the Fallopian tubes and
the  uterus, however contracted, the ovula undergo no such risk, even in
multiparous animals, where they lie densely grouped together.  After
the  embryos have become developed and shrouded within their amnia,
their coalition ceases  to be even conceivable.   These membranes would
have to undergo previous rupture ; for the occurrence of twins within a
single amnion  is too  rare and too  inexplicable to be  here taken into
account.   How slight is the disposition amongst  various  embryos to
coalesce is  shown by  those  cases of  twins, in which, owing to  confined
space, the one is almost flattened by compression, without any coalition
having taken place.
   It results from the  above that the aforesaid division of malformations
with supernumerary parts, and the  assumption of twofold  germs and
their coalition,  are inadmissible.   The  task,  therefore,  still  devolves
upon us of explaining this  class of malformations.   Accordingly we
have to observe that:
   1. The cause might consist in an anomalous formation of the ovum in
its  unimpregnated  state.   Bischoff  adduces in favor of this view  the
occurrence of double yelks, as also the aforesaid hereditary  character of
twin formations and  their recurrence out of the  same mother.  This
cause  would, however, apply only to more perfect twin formations, it
being difficult to imagine a mere supernumerary finger or even extremity
to have a similar origin.
   2. Some have long conceived the formative power within the germ to be
endowed with  unusual energy, causing the development of a  greater
number of parts than belong  to  the species.   The facts observed by
Wolff,  Von Bar, and Reichert, certainly relate to twin formations of
a very early stage of  development.  Still this stage is too far advanced 
THE  NUMBER OF PARTS.
39
to be  cited in direct  support  of an assumed  augmentation of plastic
power  in the germ, as determining either  an approach to the formation,
out of  the plastic materials of the yelk, of a double, or even of the par-
tition of a single zona pellucida.   On the other hand, these cases are of
a period so  early, and of  characters so marked, as to render it almost
self-evident  that the cause of the malformation  must have been a pri-
mordial one, or at least have dated from the earliest period.   The mul-
tiplication of individual parts is possible at  a later period, provided the
germ remain for them unchanged.
   3. One species  of twin formations can at the  present time only be
satisfactorily explained by the  assumption of an ovum in ovo,—one
ovum  being primitively enclosed within another.  We refer to twin
formations from invagination or  implantation,  so-termed conceptionlike
germination (Meckel)—diplogenese par penetration.  One foetus incloses,
at some part, another  imperfect foetus—a foetus  in foetu: or  else  one
foetus  is at some one point, commonly at the skull or palate, united with
another foetus, through the medium of a more or less perfect umbilical
cord.   Meckel regarded  the foetus in foetu  as  a product of conception,
and sought  to maintain this view by an appeal to analogy;  adducing,
for example, the formation  of hair  and teeth independently of copula-
tion,  sexless  multiplication and propagation, regeneration.  At  the
present day monosexual conception is  hardly—multiplication by cotyle-
dons or offshoots, in nowise—admissible.   Certain of the observations
in point relate to cases of malformation in the early embryo, in the third
and seventh month, for example, in which  a  conceptionlike product is
simply impossible.   The  occurrence of ovum in  ovo, in the instance of
birds,  at least, is proved ; the intussusception of one ovum into another
during development is, on the other hand, not conceivable.
   4. Finally, an augmented number of parts depends not unfrequently
upon arrest of development, and  the anatomical excess is reduced to  one
of no real physiological import;  for example, the true diverticulum of
the intestine as  the remnant  of the  omphalo-mesenteric duct, double
frontal bones, and the like.
   Malformations, with  supernumerary parts, are  divisible into several
orders, which, with their principal species, are as follows:

   1st  order.—Malformations  with  individual parts  supernumerary—
head and trunk  being single.
   Dignathus.   Malformation with supernumerary lower jaw.
   Caudatus.  Human foetus with tail-like process at the os sacrum.
   Polydaetylus.  Malformation with supernumerary fingers.
   Notomeles.  Monstrosity  having supernumerary limbs at the back.
   Pygomeles.   Having supernumerary limbs at the os sacrum.
   Grastromeles.   With supernumerary limbs at the normal extremities.
   To which are  to be added:
       1. Supernumerary skull bones.
       2.        "       vertebrae.
       3.        «       ribs.
       4.        "       muscles.
       5.        "       teeth. 
40
ANOMALIES IN RESPECT OF
       6. Double tongue (always superimposed).
       7. Double oesophagus.
       8. True diverticulum of intestine.
       9. Double caecum and vermiform process.
      10. Double pancreatic duct.
      11. Double hepatic duct.
      12. Manifold spleen.
      13. Double heart.
      14. Multiplicity of kidneys, probably due to arrest of development.
      15. Double or triple ureters.
      16. Double bladder.
      17. Triple testicle  (?).
      18. Double penis and clitoris (?).
      19. Double uterus (U.  duplex, bicornis, bilocularis);  to be  re-
           garded altogether as arrest of development.
      20. Testicles  and  ovaries, seminal  ducts,  seminal  vesicles, Fal-
           lopian tubes, uterus, &c, in the same  individual.
      21. Supernumerary mammae.

  2d order.—Twin monstrosities, with double head and trunk.
  (a.) Double formation  of the upper portions of  the body.
  Heteroprosopus.   Two countenances; the one  perfect, the other im-
perfect.
  Bicranus.   Double skull;  countenance either  single, or double and
conjoined; lower jaw single.
  Monocranus.   Single  skull;  countenance  partially double;   brain
double, but unequally so; three or four eyes.
  Biprosopus.   Double  countenance; the faces and heads  are  com-
pletely separate, or the separation  affects the faces  to the  zygomatic
arches only;  lower jaw invariably double.
  Bicephalus.   Two entirely  separate heads, with two (seldom three)
upper, and two (seldom three) lower extremities.
  Thoraco-gastrodidymus.   Two heads and necks, thorax and abdomen
united into one; four upper and two or three lower extremities.   (The
Sardinian twin sisters.)
  Gf-astrodidymus.   Twins united  at  the  lower part  of the belly; the
four inferior extremities branch off from the sides in pairs, at right angles.
  Pygodidymus (Gurlt), Pygopages (G. St. Hilaire).   Two completely
distinct bodies, conjoined at their  ossa sacra or  coccygis.  [The  well-
known Hungarian sisters, Helena and Judith, born in the year  1701,
who survived their 22d year.]
  {b.)  Double formation of the nether parts of the body.
  Bipygus or Monocephalus  (Gurlt), Thoradelphus  (G.  St. Hilaire).
Head, neck, and thorax single; abdomina and posterior parts separate;
two or four upper, always four lower, extremities.
  Heterodidymus  (Gurlt), Heteradelphus (G. St. Hilaire); so-called
parasite  formation.   A large, regularly formed body, bearing, at the
chest or belly, another, more  or less incomplete.
  Bihypogastricus;  so-called Janus  formation.  Double body, more  or
less coalescent above; separate from the  umbilicus downwards.  Here 
THE  NUMBER  OF  PARTS.
41
 either two heads are united with the two countenances (one of which is
 commonly defective), presenting in opposite directions;  or else there is
 but a single (perhaps defective)  countenance,  with a double coalescent
 head.  The trunk is double, united  down to the umbilicus, and  has four
 upper and four lower extremities.
   Symphysocephalus (Barkow),  Cephalopages (G.  St.  Hilaire).   Twin
 monstrosity united at the head;  the twins may be perfect, or of the one
 nothing may exist except the head.
   (c.) Double  formation, both above and below.
   Biprosopus  dimdoeus (Barkow),  Tetrascelus (Gurlt).  Two heads,
 united at the sides ;  thorax and abdomen coalescent;  two or four upper
 extremities; urinary and generative organs, as also the inferior extremi-
 ties, double.
   Hemipages  (G. St.  Hil.)  The heads  superficially  coherent at the
 sides; lower jaw in  common; neck, thorax, and abdomen as far down as
 the umbilicus,  coalescent; pelves separate; four upper  and four lower
 extremities.
    Thoracodidymus (Gurlt).   Two distinct bodies united at the thorax.
   Xyphopages.   Two perfectly distinct bodies, united only in the vici-
 nity of the ensiform process.  (The well-known Siamese twin brothers.)
   3d order.—Twin  malformations through implantation.
   Cryptodidymus (Gurlt);  so-called foetus in  foetu.   The greater, per-
 fect foetus  bears  at some point  beneath the skin, or within its natural
 cavities, a second, smaller, and imperfect foetus.
   Omphalo-cranodidymus.   The umbilical cord, together  with the rudi-
 ment of the one foetus,  rooted within the skull of the other.
   Epignathus.  An imperfect foetus rooted, with  its  bloodvessels, at
 the  palate of a more perfect  foetus.

   4th order.—Triple monstrosities.   Their existence is  confirmed  by
 modern researches.
   Supernumerary parts may be normal, both in form and  structure;  in
 both respects, however, they are  frequently in various degrees defective.
   The frequency of duplicate forms varies in different portions of the
 body; for example,  a multiplication of viscera, or of organs of sense, is
 far more rare than of extremities.
   It will be seen from the  above,  that in twin monstrosities the con-
 nection between two individuals is either  a mere superficial one, occur-
 ring through the medium of skin and of bone, or else  one involving,  at
 the point of union, the blending of cavities of the body, and the union,
 in various degrees, of the same organs in the two individuals.
   Acquired preternatural increase of number consists,  in man and in
 the  higher  animals, in a multiplication of the elementary constituent
 parts of a tissue,—of the essential or the  secondary structural elements
 which  enter into  the composition of  an organ.   It is, therefore, the
 manifestation of increase of mass or density in an organ—never of the
 development of new, complex ones.   Still, the arrest or  alienation  of
tissues developed for the repair of injuries, or of destructive morbid pro-
 cesses, does  sometimes determine the formation of supernumerary appa-
ratuses foreign  to the standard of the organism; for example, anomalous
excretory ducts; accessory articulations. 
42
ANOMALIES OF SIZE.
                         CHAPTER  II.

                       ANOMALIES OF SIZE.

  Anomalies of volume manifest themselves as  irregularities in magni-
tude, and as their opposite, diminutiveness, both being either congenital
or acquired.   They are often relative only,  that  is,  applicable to one
period of development or of life.  Again,  their significance and import
may be limited to the proportions of the organ  concerned,  as in small-
ness of the brain; in enlargement  of the  heart.  Finally,  they refer,
either uniformly or unequally, to the entire body or to individual organs.

                       ABNORMAL  MAGNITUDE.

  Congenital abnormal  magnitude is sometimes general.   In relation to
the entire body it is termed gigantic growth—macrosomia.  Some chil-
dren  are born inordinately large and powerful, and endowed with other
marks of precocious  development besides;  for instance, closure of the
sutures, unusual strength and length of hair, extrusion of one  or more
teeth.   Others, impelled by innate predisposition, undergo preternatural
growth during youth, and eventually arrive at dimensions exceeding the
ordinary standard—in a word, grow up giants.  Giant stature  may de-
pend upon the equal and proportioned lengthening of all the parts, or
upon the predominant length  of certain sections  of the body, especially
of the lower  extremities.  Giant stature  does  not needs imply corre-
sponding development of the  substance of  organs  and parts, certain of
which  may possibly have been checked in their growth; for example,
the muscular system, the heart, the brain, the adipose tissue, the organs
of generation.
  Preternatural dimensions of individual organs of the body, both con-
genital and acquired, are of far more frequent occurrence.  These origi-
nate in a primary anomaly or in excessive plastic  activity of the germ,
or,  again, in  hypertrophy, or in  the dilatation of hollow  organs,  or,
lastly, in a variety of diseases in which the  textures of organs become
involved at different  periods of intra- and  of  extra-uterine life.   These
last consist for the most part, in hyperaemia, inflammation, and all kinds
of heterologous formations.   Congenital enlargement sometimes  imports
arrest of development, as, for example, a preternaturally large  thymus
gland.
  Hypertrophy and the dilatation  of hollow  organs  require to be con-
sidered somewhat more  at large.

                          HYPERTROPHY.

  Hypertrophy consists, as the term implies, in  augmented nutrition,
resulting in increase of  mass, and generally also of volume.  Long ere
the term  hypertrophy,  and even  the idea it conveys, were formally re-
cognized in science, not only had the possibility of an increase of mass 
ANOMALIES OF SIZE.
43
and  volume  without  material  destruction of  texture been speculated
upon, but the fact itself actually observed in  every variety of organ.
Even up to the present time, however, the recognition of this species of
anomaly has been characterized by a great want of clearness  and pre-
cision.   It is reserved for the discrimination of  the present  generation,
by a searching comparative inquiry, based upon a more familiar ac-
quaintance with the normal relations of the  structure and admixture of
organs, and  aided by the physical appliances now at our command, to
make an important progressive step over this wide and fertile field.
  1. Simple augmented nutrition, the increment of mass and of volume,
not  dependent upon  the  accession of any element foreign to the organ
concerned—true hypertrophy.
  2.  Anomalous augmented nutrition.   The increase of mass and of
volume is here founded upon the accession of matter alien to the organ
concerned, be it formless  blastema or determinate form-element.   This
anomalous matter, when uniformly incorporated with the texture of the
organ, that is, received both betwixt  and within  the definite structural
elements, manifests itself  as infiltration of the parenchyma—false hy-
pertrophy.  It approximates  closely to heterologous growth.
   Such are the two sections into which, as a preliminary step, we would
distinguish all the so-called hypertrophies.  Each will, however, have to
be specially considered in the sequel.
   Widely  as the two hypertrophies  should appear  to differ from each
other, and little as, strictly speaking, the second series  belongs hither,
its consideration in this place will be found preferable as regards practi-
cal utility, and expedient for other weighty reasons.
   (a.) From true hypertrophy to false there are insensible gradations,
both qualitative and quantitative,  and  both  forms  may coexist in the
same organ.  Thus, augmentation of the fatty contents of  the hepatic
cells is,  by the addition of free fat and by a change in the quality of the
fat,  exalted into a palpable heterologous process.
   (b.) Between the two  series there exists the common connecting link
that both are based upon an anomaly of the  crasis; that, provided no
obvious local causes prevail, both are engendered by a peculiar, personal,
more or less defined,  morbid tendency of general nutrition.
  Every organ is by nature  susceptible of, and  almost every one has
with more or less of  precision  been described as actually found affected
with, hypertrophy.   This  does not, however, now apply equally to both
categories  of hypertrophy—that of the areolar and of adipose tissues,
and of the muscles, more especially the organic, commonly manifesting
itself as true, that of the  so-called  parenchymatous organs still more
commonly as false hypertrophy.
   (a.)  True hypertrophy.
   True hypertrophy  appears, dpriori, incontestable,  and numberless in-
stances have been recorded of  its occurrence in every part of the body.
It is remarkable, however, that  when tested by an analysis, with refer-
ence to elementary texture and development, the proof is attended with
extraordinary difficulty as regards the most important organs and tissues.
   When it is the question, not of an  obvious augmentation of the less 
44
ANOMALIES OF SIZE.
important components of an  organ—for example, of the areolar,  the
fibrous, the adipose tissues—but of a multiplication of the essential struc-
tural elements, the positive proof  by elementary  analysis often fails,
although, both before and after death, the characters of  the  organ may
seem quite sufficiently exaggerated to warrant the assumption of true hy-
pertrophy.                                                  •
  Apart from a development of substance  resulting from extraordinary
succulence of  the texture—that is, from its imbibing an excess of amor-
phous plasma  more or less  rich in nutrimental substances—hypertrophy
can only depend either upon a multiplication of the essential textural
elements by an  accession of new ones,  or else  upon an enlargement of
the original ones.   Upon this  point a generalization is  not  feasible at
the present day, and it must suffice to set forth in due succession the re-
sults of researches touching special  hypertrophies.
  We may specify, as unquestionable, hypertrophy  of the areolar, of the
fibrous, and of the adipose  tissues;  of the common integuments,  includ-
ing, not alone  the cutis and the papillary bodies, but also the sebaceous
glands and the epidermidal formations;  of the  mucous membranes  and
their follicles; and lastly, of the  bones.
  Hypertrophy cannot indeed be  demonstrated by a comparative  enume-
ration of the form-elements;  and the size of  the latter varies considera-
bly even in the physiological  state.  Where, however,  the  increase of
mass is obvious,  and there  is  no  accession of heterogeneous  elements,
the sum of the primitive form-elements  must needs have become multi-
plied, and hypertrophy exist.   We find, too, in the involved textures—
for example, in areolar tissue—an extraordinary number  of the elements
in their embryonic stages.
  Hypertrophy  of muscle,  however  simple  it  may seem, is in  reality
most difficult of  proof.  The increase of  mass and  volume in a  hyper-
trophied  muscle certainly seems due  to  augmentation  of its  amount of
fleshy fibres; positive evidence, however, at least with respect to the stri-
ated muscles, has hitherto been wanting.   An' enumeration of the primi-
tive  fibres  is  not  feasible, nor have  elements obviously engaged in the
embryonic  phases  of new muscle-formation been as yet detected.  Still
less has an enlargement of the primitive muscular fibres, through increase
in the amount  of their primitive fibrils, been made out.   That the hyper-
trophy consists simply in the augmented  growth of the  myolemma is dis-
proved by the saturated dye, the  extraordinary resiliency, the functional
energy, for  example,  of  a  hypertrophied biceps brachii.  Least of all
could it be explained  on  the ground  of  augmented fat  formation—the
effect of  excessive development of fat, in whatever  shape, being to repel
the growth  of muscle.  The last two propositions  are moreover  refuted
by the hypertrophy of organic muscles.
  The examination of hypertrophied hearts, for which the opportunity
is frequent,  offers but  little assistance towards the  solution of the pro-
blem, more especially where the increase of mass is  considerable.  A new
accession of muscular fibres is not manifest.   On  the contrary,  in pro-
portion to the  diminished energy  of the organ, their fibrils are found in
the  progress  of reduction  to a partially dark-colored molecule, and of
gradual extinction.  One thing alone is  evidently adventitious, namely, 
ANOMALIESOFSIZE.                    45
irregular  aggregations  of an amorphous fibro-laminated  blastema,  co-
piously interspersed with nuclei in different  grades of development into
areolar tissue, and of areolar tissue itself, together with a large propor-
tion of free fat and of adipose tissue.
  In the hypertrophy of organic muscle the  characters are more clearly
defined.   Here, along with  nuclei, we meet with  little, flat, elongated,
and nucleated  bodies, the rudiments of new  fibres.  A marked instance
of hypertrophy of this  nature is afforded, amongst others, by the preg-
nant uterus, which, at  the same time, exemplifies the disintegration of
fibre, and the lingering  of a multiplicity of nuclei,  which are themselves
eventually absorbed.
  Even hypertrophy of the nervous system is little more than a problem.
The development of fresh nervous filaments is unproved and even impro-
bable.   Nor  is the enlargement of the nerve-tubules through increase of
their contents more readily demonstrable.  In  the central organs, and
particularly in the brain, the anomaly consists in an accumulation of  the
minute granular connecting mass interstitial to the nerve-tubules.   At
the circumference it can consist  only of an  augmentation of the  neuri-
lemma.   In  the ganglia the  accession of new ganglion-cells, though  not
ascertained,  is rendered probable by the regeneration of excised ganglia.
   One of the hypertrophies most frequently  discussed is that of glandu-
lar bodies.   We shall pass over,  for the present, the false  hypertrophies
so frequent,  particularly in the liver, the spleen, and the kidneys.   That
of other—for example,  the mammary, the salivary—glands may consist
in an augmentation either of some constituent of secondary importance
—for example, areolar  or adipose tissue—or of the parenchyma itself;
and it  is with evidence respecting this last form that we are here princi-
pally concerned.
  Examined with the naked  eye, the parenchyma of the enlarged pro-
state gland, as that best adapted for this experiment, certainly appears
to have undergone an increase of mass.   This  might be brought about
either  by the creation of new acini (lobules), or by the  enlargement of
existing ones, through the apposition of fresh enchyma-cells; or, lastly,
by the co-operation of  both.  The  appearances in hypertrophy of the
prostate gland render the new formation of lobules and of lobes highly
probable.   Henle's  observations, however, of  the  existence of solitary
enchyma-cells  in the vicinity of  the glandular  lobules in the lachrymal
gland of a calf, and still more, what is very readily witnessed,  in hyper-
trophied thyroid glands, render  probable the  new formation of such
gland-cells,  and,  through the resorption of their  partition walls, their
blending with the lobules so as positively to enlarge these.
  A peculiar kind  of  hypertrophy, concurrent with dilatation of the
cavities of the acini, is a very  frequent cause of the enlargement  of
glandular formations.   This  dilatation is due to an augmented secretion
taking  place  within the  follicles, determined by the same local or general
causes  as  the hypertrophy itself;   and  this latter consists in an increase
of mass in the investing fibres of the follicles.   This condition is imme-
diately followed by the  expansion or degeneration of the follicle to a
dilated cyst-like cell, with a stouter lamina of enveloping fibres.  At the
same time the secretion  may become alienated both  in  quantity and in 
46
ANOMALIES OF SIZE.
quality, until a cyst is completed with contents  altogether alien to the
native secretion of the gland.  This is witnessed in the follicles of the
thyroid gland, in the Malpighian bodies of the kidneys, in the Graafian
follicles, and in the acini of the salivary glands; in the mucous follicles,
particularly those of the cervix  uteri, where, even  in  the  physiological
state, they frequently dilate into capacious, thick-coated cysts, rupture,
and discharge their contents.                                       m
  Evidence of hypertrophy of the liver, of the spleen,  of the  lymphatic
glands,  is hardly obtainable.
  The idea of a hypertrophy of the liver from the accessory formation
of new hepatic cells would  not indeed be  discordant with our notions of
the functional importance of that organ.  All anatomical proof is, how-
ever,  unattainable.   That, on  the other hand, upon which  it  more
obviously  depends, is turgescence of the hepatic cells from an increased
proportion of fat and of bile, together with hyperaemia of the capillaries.
This condition determines the more or less marked development of what
is called the secreting substance of  the  liver,—one-sided hypertrophy of
the liver,  as it is termed, or nutmeg liver.
  Hypertrophy of the spleen must be referred, first, indeed, to the rein-
forcement of its fibrous  framework, but mainly to augmentation of the
pulpy parenchyma of the spleen, that is, of the elements out of which it
is constructed.
  Nor  can hypertrophy of the lymphatic glands be well  traced to the
adventitious development of new lymphatic vessels between their paren-
chyma, but rather to increase of the parenchyma between the lymphatic
vessels.   It is  certain, at  least, that in atrophy, the  lymphatic vessels
become deficient in parenchyma.
  Hypertrophy of the lungs consists not in the addition of new cells, but
in an augmentation of matter in the parietes of the existing ones.  The
ample,  energetic (vicariating) function, moreover, of a hypertrophied
lung  seems to imply a multiplication of the  capillary vessels by the
creation of new ones.  Thus, again, hypertrophy of the corpora  caver-
nosa  does not depend  upon the  addition of new cellular spaces, or their
increase through the  development of new septa, but  upon increase of
substance, thickening  of the walls of the cellular  spaces,  with simulta-
neous dilatation of these latter.
  (b.) False hypertrophy.
  This has been already  adverted  to  as a heterologous  product.  As
Buch  it occurs frequently in the form of infiltration.  False hypertrophy
is for the most part cognizable at a glance from the alienation which the
general characters of  the organ have undergone.   Very marked  hyper-
trophies of this  kind  are  found to  affect the liver, and with  rather less
frequency the spleen and  even the kidneys ; presenting, in the instance
of  the  two former, what  is commonly termed  hypertrophy,  physconia,
engorgement, &c.  These  manifest themselves in the shape of fatty liver,
waxy liver, of albuminous, lardaceous  infiltration of that viscus, of the
spleen, of the kidneys, and they will be reconsidered  under the head of
heterologous growths.  They not rarely attain to a very high grade, are
always distinguished as being palpably based in a constitutional dyscrasis, 
ANOMALIES OF  SIZE.
47
and are,  proportionately to the rapidity or slowness of their develop-
ment, attended or unattended with pain.
   To these hypertrophies, moreover,  properly belongs  the ultimate
degeneration of hypertrophied and dilated glandular follicles into cysts.
   Finally, we may here  class all hypertrophies founded upon products
of inflammation, so far as  they consist  in the adventitious development
of a blastema foreign to the texture involved, and convertible into areolar
and fibroid tissue.

   Hypertrophy attacks one, or a few disconnected, but for the most part
nearly kindred organs;  or, again, an entire system—for  example, the
osseous, the lymphatic system.  The general hypertrophy called poly-
sarcia or corpulence, consists both in the  excessive development of fat,
and in  extraordinary succulence of  the  soft tissues, more especially of
the areolar.
   Hypertrophied  organs offer a variety of remarkable changes.  The
volume is usually augmented,—more obviously so  in  the  case of false
hypertrophies.  Now and then the natural volume is retained, the failure
of increase of volume being compensated for by augmented density of
the organ, or  some one anatomical constituent  becoming hypertrophied
at the expense of another one, which wastes in a corresponding degree.
In hollow organs we distinguish between a simple  hypertrophy with
normal capacity, an excentrical  with dilatation, and a concentrical with
diminution of the cavity.   In this last the volume  of  the organ may be
augmented, or normal, or  even diminished.  Examples are  afforded in
hypertrophies of the heart, of the uterus, &c.
   The weight of hypertrophied organs  corresponds with their increase
of volume and of density.
   The shape always undergoes a change proportionate  to the degree of
the enlargement.   Generally speaking, hypertrophied organs assume  a
certain  roundness, losing their edges, their angles, and their flat sur-
faces.   In the case of some organs, and of the liver in particular, the
marked character of such disfigurement  is not devoid of pathognomonic
significance.
   The color is, in true  hypertrophy, the normal—only of deeper  tint.
Take, for example, the saturated red in true hypertrophy of muscular
flesh, the saturated twofold coloration of nutmeg liver.   In false  hyper-
trophy,  the coloration suffers various alterations.
   The consistence of a  hypertrophied organ is often unchanged, often
increased, sometimes diminished.   A remarkable degree of density and
of resiliency characterizes hypertrophied muscle, more especially in the
right ventricle of the heart; and, again, in hypertrophy of  the  spleen
referrible to mechanical hyperaemia, and unattended by obvious enlarge-
ment.   The same observation  applies  to  false hypertrophies, in parti-
cular to brawn-like infiltration of the liver, the spleen, and the kidneys.
Fatty degeneration of the liver is marked by a diminution of consistence.
   The bloodvessels of hypertrophied organs sometimes present a dilated
calibre and thickened (hypertrophied) coats.   This  is especially percep-
tible in congestion and hypertrophy of long standing; not so, or at least
not in a marked degree, in other  cases.   Does the  accessory formation 
48
ANOMALIES OF  SIZE.
of new structural elements in the hypertrophied organ imply that of new
bloodvessels  likewise ?  Direct experience affords  no^ information upon
this point.   In relation to the hypertrophy of vicariating organs, and of
the lungs more particularly,  it  would  be  reasonable,  where vicarious
action really is in force, to take for granted  the accessory formation of
new capillaries.   The  nerves of hypertrophied  organs  are occasionally
found considerably thicker than natural.
   The causes of hypertrophy are:
   1. Morbid increase of the quantity of blood in the capillaries of, and
retarded circulation in, the affected organ ; repeated and abiding hyper-
aemia.   Examples are  furnished in  particular by the frequent hypertro-
phies of the abdominal viscera arising out of mechanical hyperaemia, of
the mucous membranes in organic diseases of  the  heart,  of the areolar
tissue in the lower extremities in  a varicose condition of their veins, and,
lastly, by the hypertrophies of the mucous membranes brought about by
the hyperaemia entailed by repeated inflammation.
   2. Augmented, violent  action  induced by various direct or reflected
stimuli.  Examples present themselves in hypertrophy of the voluntary
muscles, of the heart, of the organic fleshy tunics.
   3. The groundwork  of a lengthy series of hypertrophies consists in a
constitutional vice of nutrition and in an anomalous blood-crasis.   The
hypertrophy  is here the expression, the symptom, of general impairment.
This applies to true, and with greater force to  false hypertrophy.   To
this  class belong  hyperostosis,  excessive development  of fat,  endemic
goitre,—hypertrophy of the brain, and hypertrophy  of the lymphatic
glands in rhachitism,—the excessive development of fat  with  simulta-
neous impairment of its quality in  alcohol-dyscrasis,—the conditions of
fatty, of waxy liver, of brawny infiltration of this  organ, of the spleen,
of the kidneys in tuberculosis, rhachitisms, inveterate syphilis, &c.
   4. Inflammation; the  result of  which is so-called  inflammatory hy-
pertrophy, to which we shall have to recur  by-and-by.  It engenders
true hypertrophy in areolar  and osseous textures alone ;  in  all the rest,
through the fresh deposition of areolar and of fibroid tissues, false hyper-
trophy.
   Hypertrophies of both kinds are  either congenital, or, what is far more
frequent, acquired during extra-uterine life.
   The course of hypertrophies is for the most part chronic.  Neverthe-
less, they not rarely form within a surprisingly  short  period, or from
time to time rapidly increase.   They are then  often painful affections,
as, for example, the  acutely developed fatty liver.
   Hypertrophy, when it has attained a high degree, impairs the function
of the affected organ, whilst the latter,  by its increase of weight and of
volume, obstructs the function of neighboring parts.
   Of itself it commonly proves  fatal through palsy,  the result of the
ultimate disproportion  between the bulk of the hypertrophied organ and
the powers of innervation.  As examples may be cited hypertrophies of
the heart, palsy of the hypertrophied intestine above a  stricture,  palsy
of the hypertrophied urinary bladder, and the like.
   A proper discrimination is requisite between increase  of volume from
hypertrophy and the dilatation of hollow organs, more especially if asso- 
ANOMALIES  OF  SIZE.
49
ciated with attenuation of the parietes.  Dilatation is generally coupled
with hypertrophy of the walls of the dilated organ,—termed active dila-
tation, co-significant with excentrical  hypertrophy.  Simple dilatation,
in which the walls are of their natural thickness, is a kindred form.  Di-
latation may, however, be conjoined with attenuation of the walls; it is
then denominated passive dilatation.
   The causes of the dilatation of hollow organs are various.
   1.  Mechanical impediments, which obstruct the free passage and
egression of the contents of the different canals and  reservoirs.   They
occasion dilatation either beyond or behind  their seat, and manifest
themselves—
   (a.) As local constriction of calibre, through pressure from without.
   (b.) As coarctation consequent upon hypertrophy and change of tex-
ture in the walls of the organ.  In instances rare, except in  disease of
the heart, as dilatation.  Thus, whereas in the intestinal canal it is the
accumulation of its  contents, on  the  other hand, in dilatation of the
orifices of the heart it is the increased diameter of the blood-column, in
insufficiency of  the heart-valves  the  regurgitation  of  the  blood, that
furnishes the mechanical impediment.
   (c.) As obturation of canals with substances of various kinds, whether
introduced from without or begotten within the organism, whether closing
up by their  bulk or  obstructing by  their aggregation,—in a word, as
foreign bodies, secretions, &c.
   Other local  causes, however, besides the above-mentioned—accumula-
tions of foreign bodies, of self-engendered deposits—are in like manner
productive of dilatation.
   2. Paralysis  of the  contractile elements in the walls of the organ,
whether peripherous, and consecutive  to mechanical, concussive violence,
tension, &c, to  disease of texture, especially inflammation; or  deter-
mined by affection of the nervous centres.
   3. Diseases of texture; for example, fatty  degeneration, particularly
of the heart.
   4. Inflammations.
   The different causes frequently act in  unison in various sequences.
Thus, coarctation begets accumulation of contents.  This, together with
a certain relative amount of existing dilatation,  occasions  paralysis of
the organ.   The paralysis causes  dilatation, and  thereby  accumulation
of the contents,  which again, in turn, mechanically promotes  the dilata-
tion.
   Dilatation destroys life through  paralysis, either simply  or with the
concurrence of asthenic stasis, inflammation, and  gangrene, towards the
establishment  of which the contact of  retained contents in the progress
of decomposition contributes its part.   Take for  example the intestinal
canal, the urinary bladder, &c.
   Sudden dilatation is wont to assume the passive character, a superve-
nient hypertrophy being more marked in the inverse ratio of the celerity
with which the dilatation is brought about.
   Increase of  volume in one direction at the expense of the general bulk
of the organ, the result of forcible tension, is  distinct from hyper-
trophy.
   VOL. I.                           4 
50
ANOMALIES OF  SIZE.
                     ABNORMAL  DIMINUTIVENESS.

   Congenital abnormal diminutiveness affects the entire body, as ^ dwarf
stature (microsomia), the individuals  being termed  dwarfs,  or pigmies.
These are either born diminutive, or, owing  to  inherent predisposition,
not developed after birth to the ordinary stature.   Dwarf-growth mani-
fests itself either in  the corporal  development remaining stationary  at
the stage of childhood,  the  not unpleasing outlines and proportions  of
which it then retains, or else it is  founded  in an arrest in the growth  of
the bones,  especially those of the  lower extremities, with simultaneous
malformation of the  osseous trunk.  It is marked by a disproportion  in
the more important parts  of the body—largeness and hydrocephalic
shape  of the  skull; length of trunk coupled with shortness  of extremi-
ties, especially of the inferior ones;  deformity of bones, consisting  in
thickness, especially of the articular terminations.   This latter dwarf-
formation is always congenital, and the bone affection upon which it de-
pends  has been  designated as congenital rhachitis; against which, how-
ever, we have as yet to urge that, however much its features resemble
those of the rickets of childhood, the direct evidence of its identity with
the latter is wanting.
  Accordingly,  dwarf-growths may depend, either upon a primitive  vice
of plasticity,  or in an anomaly of  development affecting specifically the
osseous system.   Growth may, moreover, become checked at an earlier
or later period, subsequent to birth,  by constitutional maladies of an ex-
hausting kind, both congenital and acquired, and especially  by such  as
affect the brain or spinal medulla.
  Partial diminutiveness affects individual organs, systems, or sections
of the  body.   It is founded sometimes in a primitive anomaly of, or  in
defective plasticity in, the germ ;  in pressure and in restriction of space
within the uterus; or, again, in a  hindrance to growth after  birth, re-
sulting from exhausting  diseases, from paralysis;  lastly,  in atrophy.
Where larger sections of the body are affected, such disproportions result
as are  observed in giant-growth, in dwarf-growth, and in numerous de-
scriptions of monstrosity.  Although it may affect  every organ  and
system, it is  nevertheless  most conspicuous  in  the following: namely,
the brain (and  skull) [microcephalia];  the eyes [microphthalmus], the
inferior maxilla [brachygnathus], the  lungs (and thorax), the stomach
and intestinal canal,  the common  integuments (shortness), the muscles,
the skeleton,  the heart and vascular system  (especially  the  aortal), the
generative  apparatus.
  It is necessary to  observe, that—
  (a.)  In monstrosities, accessory, supernumerary parts are  very fre-
quently diminutive.
  (b.)  Formations checked in the development of their mass and volume,
often exhibit  an arrest in the development of their texture ; for example,
bones, muscles.
  (c.)  Preternaturally diminutive  organs often display some other kind
of deformity, referable to the same causal relations.
  (d.)  Next  to  diminutiveness is  total  absence, which, in reality, often 
ANOMALIES  OF  SIZE.
51
applies to individual formations entering into the composition of a com-
plex part or system.
   In  hollow  organs preternatural  diminutiveness  manifests itself as
coarctation, and even as complete imperviousness, which, when affecting
the external orifice of canals, is termed imperforatio, atresia.
   As  contrasting with hypertrophy, atrophy here  demands a special
consideration.

                              ATROPHY.
   Atrophy, wasting  [tabes], consists in the withdrawal from a forma-
tion, after it has  reached a certain grade of maturity and  bulk, of its
constituent  elements, without any compensating regeneration of these;
the result being decrease of substance, usually coupled  with diminution
of volume.
   General atrophy attacks  simultaneously, or in rapid succession, many
organs and systems, if not all.  Partial atrophy, one organ exclusively,
or at least preferably.   To the latter we shall at once direct our atten-
tion.
   As with hypertrophy, so  every  organ is liable to become affected with
atrophy.
   Atrophy  may, in the first  place, be essentially primary,  that is, de-
veloped in an organ as its first  and sole anomaly, through influences
more or less palpable, but external to such organ.  Or, again, it may be
secondary, that is, the result of previous textural  alteration in the organ.
The first is akin and analogous to  the periodical intra- and extra-uterine
processes of involution of certain formations,  as also to the senile atrophy
or marasmus  of organs.
   Primary partial atrophy is often, indeed,  purely  local; in not a few
instances, however, it is probably conditional upon a general derange-
ment of nutrition, of which, in such case, it  is but the manifestation or
symptom.
   Causes of partial atrophy are:
   1. Biminished supply of blood—of alimentary  fluid—owing to com-
pression, obturation, coarctation,  or  obliteration of  the  afferent blood-
vessels ; for example, partial atrophy with  lobulation of the liver  from
adhesive phlebitis of branches of the portal vein, atrophy of the cartila-
ginous  investments of the joints from sclerosis of the spongy condyles,
and  the like.  Thickening of the minute   and  capillary vessels  from
within may co-operate with ossification of the great arteries in producing
atrophy, especially in the brain, by rendering  the walls of such vessels
impermeable to the plasma of the blood.
  2. Exhausting disease, or healing process; for  example, atrophy of
the bones and of  their adjacent soft parts as a consequence of caries, of
destructive suppuration in the effort to repair injuries;  atrophy of the
uterus after childbed, and exhausting puerperal diseases, &c.
  3. Biminished innervation, paralysis, or impeded action of an organ
owing  to mischief of a  mechanical nature;  for  example, atrophy of
muscles in anchylosis, in luxations.
  4. Pressure and distension.—These occasion  increased absorption, a
species of atrophy designated by  the term   detritus, usura.   Even the 
52
ANOMALIES OF SIZE.
most stubborn textures are not proof against it, the rigid osseous texture
itself being in a high degree susceptible of it.   It not unfrequently ad-
vances to the degree of a lesion of continuity.
   5. Anomalies affecting  general nutrition,  and  the  blood-crasis  in
particular.—Upon  such  are based, for example, perhaps, the  untimely
decline (involution)  of the generative  organs in  either, but especially in
the male  sex;  but with more  of certainty,  several  painful  kinds  of
atrophy of the osseous system.   Acute yellow  atrophy of the liver is
unquestionably founded upon an anomaly of the crasis, whilst the thyroid
gland is atrophied by the fluids becoming impregnated  with iodine.
   6. Consecutive atrophy  depends, as already stated, upon  a previous
alteration of texture, a breaking up thereof through hemorrhage (apo-
plexy),  inflammation,  and  heterologous growths.   Two contingencies
may here arise;  either the  adventitious product and also the disabled
textural elements of the organ  may  both undergo  absorption, or else
these latter may waste away alone, leaving in their place the new pro-
duct, in the original or in subsequently diminished proportion and inde-
finite shape.  Exemplifications occur in cell-infiltration of the medullary
substance of the brain consequent upon encephalitis;  in atrophy of the
kidneys, resulting from inflammation or from Bright's granular disease;
finally, in the  merging of  muscular fibre in the  fatty degeneration  of
muscle and of normal textures in heterologous growths.
   The morphological process connected with atrophy is not known in
detail.   To judge  by a  few facts—for  example, the  reduction  of the
uterus after delivery, the perishing of muscular fibre in  fatty degenera-
tion, the wasting of nerves, of lymphatic glands—the process essentially
consists in the breaking down and liquefaction of the  secondary elements
(fibre), resulting from the metamorphosis of the cells and from the cells
themselves.  The nuclei at first remain,  but subsequently undergo the
same reduction and ultimate resorption.  In the  case of new growths,
this blastema, arising out of the wreck of the said elementary bodies,
may become subservient to  the construction of anomalous textures.
   With respect  to  the changes suffered  by atrophied  organs in their
physical properties, we may offer the following general remarks.
   The volume of the atrophied organ is  indeed very commonly dimi-
nished, membranous formations having become thinner :  this is, however,
by no means invariably  or immediately the case, at  least not in any
marked degree; for example, in atrophy of the lungs  or of the bones.
In hollow organs the volume may, owing to a coexistent passive dilata-
tion, even become  augmented.   In such organs' atrophy is conjoined
either with normal  capacity, simple atrophy; or else with dilatation of
the cavity, so-called eccentrical  atrophy—for example, of the heart, of
the uterus,  &c.;  or,  lastly, with  coarctation,  concentrical atrophy, in
which  the depth of the walls may  be  natural,  or even greater  than
natural.
   The weight of  atrophied  organs may be reduced, normal, or even in-
creased : in the first case, proportionately to the simplicity of the atrophy •
in the two latter cases the atrophy is consecutive, new growths supplant-
ing the original textures.
   The  shape  of atrophied organs embraces a  variety of  anomalies* 
ANOMALIES  OF  SIZE.
53
amongst which we may specify the deformity which attaches to the con-
centrical wasting of hollow organs and organs of  cellular  structure like
the bones, the  removal of the incisura  interlobularis in atrophy of the
lungs,  the tuberous gland-like  surface in  secondary atrophy  of the
kidneys, &c.
   The structure of atrophied organs involves  various, and occasionally
very marked changes.   Thus, organs of cellular, of cavernous structure,
by dint of the  absorption which takes place at the parietes of their cells
and canals, are rendered  wide-celled—for example, in the lungs and in
bones ;  and this structure eventually dwindles into a mere net  or trellis-
work.   In consecutive atrophy, a new growth of a completely different
texture occupies the place of the original structure; after inflammation,
for instance,  a  honeycombed,  meshy, or,  on the contrary,  a dense,
callous, areolar tissue.
   The  consistence is  in  like manner  subject to many changes.  It is
sometimes diminished, readily giving rise, upon slight occasion,  to lesions
of continuity;  in the osseous  system, for example.  Sometimes it  is in-
creased.  Secondary atrophy presents, in a marked degree, either con-
tingency, according to  the  particular  change  of structure.  Acute
processes of the reduction of mass  and volume  determine,  in  certain
organs, rather a  decrease—chronic  reduction rather an  increase—of
consistence.
   Atrophied organs have a tendency to paleness of color.  This, how-
ever, in some measure accords with certain changes affecting the native
pigment of organs; for example, the decoloration of muscle, of the spleen
to rust-brown,  fawn-color, or yeast-color.  The rule itself is, moreover,
subject to sundry exceptions.   Thus, the pure white  of the medullary
substance of the brain is exchanged  for  a whitish-brown.  Organs that
become atrophied without a proportionate  thinning of their capillaries,
sometimes, by  dint of  a relatively augmented supply of blood, assume a
deeper color; for example, bones, kidneys.   At the same time much de-
pends upon  the character of the atrophy;  as  in  the  cases  of red and
yellow atrophy of the liver.
   The bloodvessels of atrophied organs become reduced in calibre, col-
lapsed, and finally cut off from the atrophied organ, that is, the connec-
tion interrupted between its obliterated capillaries  and the vascular
trunk.  This, however, has, in like manner, its exceptions, as in the case
of dilatation of the trunk and ramifications of the pulmonary  artery in
atrophy and in emphysema of the lungs; in the case of dilatation of the
bloodvessels of the brain, in atrophy  of this organ.
   The nerves of atrophied organs in all probability dwindle pari passu
with the wasting of the diseased textures.
   Atrophy is sometimes an acute, but more commonly a chronic process.
In the former case it is frequently a  painful affection.
   The consequences of partial atrophy differ vastly in different  organs.
Either they are limited to a small range, to the  locality itself, or they
implicate more or  less sensibly the  entire  organism.   In this  respect,
atrophy of the central organs of the nervous system,  and of the organs
presiding over  the preparation of the blood and over the grand secretory 
51
ANOMALIES OF  FORM.
 functions, namely, of the lungs, liver, and kidneys, is of course foremost
 in importance.
   Greneral  atrophy in  the  form of emaciation, consumption,  affects,
 indeed, the entire body,  but by no means all organs and systems simulta-
 neously or in an equal degree.   Next in  order  to the falling off in the
 amount of blood, is that of the adipose, the areolar, and kindred tissues;
 then follows  that of the voluntary muscles, then of the organic fleshy
 tunics and of parenchymatous  organs,  lastly of bones;  whilst,  even in
 the highest grades of the affection, the nervous system,  so  far as relates
 to its constituent elements, remains exempt.   This  order is,  however,
 subject to many exceptions.  The wasting of  several formations low in
 the scale above laid down, occurs primitively, and offers the starting-
 point for the atrophy of the rest; for example, atrophy of bone.
   The causes are loss of fluids of whatever  kind, deficient reproduction
 of organic substance, fasting, various affections  of  the  digestive organs,
 bodily and mental exertion, inordinate activity of the nervous system in
 various ways, excessive heterologous development, dyscrasis of the blood.
   It is not rarely combined  with the hypertrophy—for the most part,
 false hypertrophy—of internal  organs,  especially  of the liver,  spleen,
 and lymphatic glands.
  A peculiar form of partial  diminution is represented in the coarctation
of canals  and cavities.  It is  often, indeed, essentially a concentrical
atrophy.  It may, however, arise from external pressure, from deficiency
of contents, from continued irritation of the sensitive parietes, or even
from  hypertrophy of,—or  from  various  heterologous  luxuriations  and
changes of texture implicating,—the said parietes.    The highest  grade
manifests itself as morbid closure (atresia).
                         CHAPTER III.

                      ANOMALIES OF FORM.

 ^ Anomaly of form, or deformity, affects either the entire body or por-
tions of it only,—general or partial deformity.  It is either primitive or
acquired; simple or complicated, that is, conjoined with anomalies of a
different nature.
  G-eneral deformity is rare, even as relates to very faulty abortions.
  To primitive, simple partial deformities belong—
  (a.)  Those in which any part is  preternaturally long, broad,  thick
spherical, angular, curved,  &c.;  for  example,  oval,  vertical  pupil
oblique uterus.                                                     '
  (6.)  The division of parenchymatous organs into two or more parts
by extraordinary lobulation  (the  lungs,  liver, spleen, kidneys) •  the
section of hollow organs by the inordinately sharp partition of a naturally 
ANOMALIES  OF  FORM.
55
double cavity, or by  septformation  in  a cavity normally single; for
example, double apex of the heart, bilocular uterus.
  Many of the former, and still more of the latter kinds bear the impress
of arrest of development, and present the images of brutes.
  Amongst primitive  complicated deformities may  be classed  most of
the instances of disproportion and of absence of symmetry manifested in
the preternatural volume  of individual organs  or sections of  organs;
secondly, those consisting in abnormal position, abnormal association,
coalition or cleftformation; and,  lastly, those founded in the superfluity
or in the deficiency of parts.
  Pre-eminent amongst them are hermaphrodites.  The forms of herma-
phroditism, strictly considered, range under  several of the heads just
specified as conditional upon anomalies  of shape.  It  would, however,
appear most suitable to discuss them here under  a single head, seeing
that from one or more fundamental anomalies inductive of hermaphroditism
there often results a marked deformity of the generative organs; seeing
also that the  character of many of  them consists essentially in a de-
parture from the normal type.   They are, in the great majority of cases,
arrests of development.
   In strict analogy with the relations of lower orders of  animals, those
malformations should be  designated as hermaphrodites,  in which the
generative organs of both sexes are found united in  a single individual.
Such monstrosities  have, from  time  immemorial,  been abundantly
described.   We must, however, unite with Joh. Miiller  and Th.  Bischoff
in rejecting the great majority of these examples. Bischoff has pointed
out the numerous sources of error by which, in such  cases, a judgment
may be  warped; as,  for instance, the  great resemblance between the
generative organs of the two sexes at an early period, the uniform type
in the development of both, the coalition of the  corpora Wolffiana,  the
errors formerly prevalent as to the primitive  identity of both sexes.   It
is, therefore, easily intelligible that a judgment  to be  relied  upon can
alone be based upon a familiar knowledge of the progressive development
of the genital organs, and of their elementary structure.  The coexistence
of testicles and of ovaries on the  same side has been  thrown into entire
discredit by the arguments of Joh. Miiller, who nevertheless admits the
occurrence of  ovaries on  one  side  and of testicles on the other.  Th.
Bischoff, however, impugns the  accuracy even of  the  latter observation.
Nor will Bischoff unconditionally admit the numerous cases of  other
portions  of the genital organs alleged to have been  found bisexual on
the same side, or male on the one side and female on  the other.   The
history of development, he affirms, sufficiently teaches us that this species
of simulation may be the result partly of an arrest, partly of a peculiar
modification in the type of development.  Moreover,  the progressive
development of the uterus, of the  seminal vesicles, of the prostate gland,
and of Cowper's glands, in both sexes, still remains, notwithstanding the
skilful investigations of J. Miiller, Rathke,  Valentin, so far matter of
uncertainty that we can hardly derive any support from  analogy with
the normal state.
  Strictly speaking, therefore, neither in man nor in the higher animals,
can hermaphroditism,  that  is, the coexistence of testicles with  ovaries, 
56
ANOMALIES  OF  FORM.
occur.   So far as relates to these essential organs  of generation, there
can be but male or but female individuals.  On the other hand, the rest
of the  genital  organs,  which  in  their  rudimental  condition closely
resemble each other in the two sexes, may, owing to some anomaly  in
the mode of their development, assume in a male individual more or less
of the feminine, in  a female individual more or less of the masculine
form—and thus, in either case, the semblance of both combined.
   If, with Bischoff, we rightly discard from  hermaphroditism,  cases  of
individuals with throughout  female  organs   but  masculine habit, and,
again,  with perfect male  organs and  feminine habit—irrespectively of a
simply undersized penis or a preternaturally developed clitoris—we may,
consistently with our usual classification, divide hermaphrodites into—
   1. Those  which being, as to the essential organs  of generation (testi-
cles and ovaries), distinctly male or female,  exhibit nevertheless some
anomaly of development  [be it arrest, overgrowth  (up to the masculine
type), or disproportion of some other kind] more or less typical of the
opposite sex.
   (a.)  Hypospadia in its highest grades, namely, on the one  side with
cleft scrotum and the  formation of a vagina-like  sinus—on the other
side, as its analogue, diminutive vagina, closure thereof into  a  raphe* or
suture, partial or entire absence of this organ, with a clitoris developed
into the semblance of a penis hypospadiaeus, or one completely channelled
with a urethra.
   (b.)  Cryptorchism: concealed testicles in  the  one case; in the other
its parallel condition,  descent of  the ovaries  into the  greater labia
pudendi.  Now and then associated  with the foregoing form.
   High grades of these anomalies constitute the so-called transverse her-
maphroditism, implying external organs of the one  and  internal of the
other sex.   The case  of  externally female and internally male organs is
by far the more common, because due  to an  arrest  in the development
of the  male  organs, whilst the opposite case  depends upon the ulterior
development of the female organs into the male type.
   (c.)  The occurrence in the male sex of a womb-like organ.
   These cases collectively constitute what is termed spurious hermaphro-
ditism.
   2. Lateral  hermaphroditism.  The presence  of testicles  and  vas
deferens, with or without seminal vesicles, on one  side,  and of ovarium
and tube on the other.   It has been before stated that Bischoff attaches
little  credit to  these  alleged cases of the coexistence  of testicle with
ovary.
   3.  True hermaphroditism  (hermaphrodite  per excessum, androgynus,
coexistence of male and  of female organs on  the same side).  With refe-
rence to these cases, recorded by Meckel and by Gurlt, Bischoff remarks
that not a single one  offers conclusive  evidence of  the union of the two
main organs of generation, the testicle and ovary, and that the seeming
dualism of the rest of the organs is explicable according to principles of
normal development.
   Amongst acquired deviations of form are to be enumerated, first, those
conditional  upon hypertrophy and atrophy;  upon change of locality and
of connection—as, for instance, hernia, prolapse, oblique position of  the 
ANOMALIES OF POSITION.
57
uterus from one-sided traction, luxation;  upon  mechanical interference
—for example, amputation, extirpation ; upon cicatrization; and, lastly,
those malformations of organs which essentially depend upon alterations
of texture—misshappen liver, for instance.
  The most frequent and marked kinds of deformity are founded upon
anomalies of the osseous system ; for instance, curvatures of the spine, of
the long cylindrical bones, dislocations, preternatural articulations, &c.
                        CHAPTER  IV.

                     ANOMALIES OF POSITION.

  Preternatural position—situs mutatus, inversus, alienus, dislocatio,
ectopia—is either congenital or acquired.   In either case, it may affect
a single organ or implicate several.
  To congenital anomalies of the kind belong:
  1.  The re-establishment  of symmetry, in  lateral asymmetria.  For
example, each lung is found to have twro lobes only, with both liver and
heart in the centre.   This is probably an arrest of development, these
organs originally occupying the  median line, and being in appearance
symmetrically constituted.
  2. Lateral transposition, displacement from side to side, affects either
only individual organs of the thoracic or abdominal cavities—the caecum
being, for instance, on the left, the heart on the right  side; or  else it
affects the aggregate of the thoracic  or  of the  abdominal  viscera; or,
lastly, and most commonly, the collective organs of both these  cavities
at once.   The type of formation is reversed, the  right greater lobe of
the liver, for instance, becoming the left,  the left becoming  the right,
the gall-bladder lying to the left  of the longitudinal fissure. As regards
the cause, it appears to Bischoff that  in the embryo at an  early  period,
the umbilical vesicle, after development of the intestine, verges towards
the left, and the allantois towrards the right, whereby  a peculiar spiral
revolution of the embryo is effected,  which may possibly  influence  the
position of the internal organs.   It is conceivable that a change  in  the
position of the germinal vesicle in the ovum might, in like  manner, give
rise to a transposition of organs.
  8.  Transposition from  above  and  below.  Thoracic organs  in  the
abdomen; abdominal in the thorax.
  4.  Transposition from front  to back;  for instance, in  the  case  of
teeth, in distortion of the extremities.
  5.  Bisplacement of individual organs from the median  line,  as for,
instance, of the falx (cerebri),—of the uterus.   Bisplacement upwards,
as in  cervical position of the heart.   Bisplacement  downwards, as in
abdominal site of the heart, pelvic position of the kidneys.
  Anomalous origin and distribution of arteries and veins.  The more
important examples hereof will be discussed  under the head of  special
anomalies of the heart.  They originate, for the most part, from blood- 
58
ANOMALIES OF  POSITION.
vessels which should have become further developed stopping short in
their progress, whilst others which should have remained diminutive, or
even have disappeared, persist and  become more  strongly  developed.
The majority represent types proper to different vertebrata—to  fishes,
amphibia, birds, and mammalia.
  The preternatural position of certain organs which, in their  develop-
ment, undergo locomotion to a  considerable extent, is specially termed
deviation, aberration.  An example offers in the descent of the testicle
beneath the femoral arch or into the perinaeum.  In truth, many anoma-
lies of position are founded in an  early aberration  in  this sense.   The
same  designation  is applied to anomalies  in  the  origin, course, and
ramification of vessels.
  Acquired transposition  is of various  kinds,  and many of  these  so
closely resemble the congenital forms, as with  difficulty  to be  distin-
guished from them.  Their import varies greatly, proportionally to—
  (a.) The importance of the organ displaced;
  (b.) The number of organs displaced;
  (c.) The extent of the displacement; and
  {d.) Especially to the rapidity with which the dislodgment takes place,
and to the corresponding strain upon various formations, more particu-
larly bloodvessels and nerves.
  (e.) The extent of the morbid complication to which the  displacement
is due;  for example, mechanical injury to the surrounding parts.
  (/.) The degree of embarrassment to which the dislodged  organs  be-
come subject; for instance, limitation of space, incarceration, exposure
to the external  air, &c.
  (g.) The amount of functional embarrassment inflicted upon organs by
the displaced parts; for  example, upon the lungs  by the intrusion  of
abdominal viscera into the thoracic cavity.
  These transpositions  are, moreover,  spontaneous,  where the organ
changes its position owing to increase of volume, of mass,  or  of weight,
in which  case  it  commonly sinks into  a lower region.   Or else they
depend upon conditions extraneous to the organ displaced;  to  which class
belong dislodgments consequent  upon atony of investing, supporting,
attaching formations, especially when of a muscular and fibrous nature.
Or they are referable to tonic spasm and retraction of fleshy, of tendi-
nous, and of ligamentous formations, as exemplified in hernia, in  curva-
ture and distortion of the spine, in luxations, in  club-foot,  &c.   Lastly,
we have to mention the displacement  of organs, through tumors, through
dislodged or enlarged neighboring organs, through accumulated  fluids,
and the like.
  The more important forms of displacement are:
  1. Hernia ;  the extrusion of one or more viscera, or of merely a por-
tion of a viscus, out of its natural cavity into a sac formed by the cir-
cumscribed  dilatation of the membranous investments of that  cavity
(hernial sac).
  2. Prolapsus; the naked extrusion  of a viscus through a natural
orifice.   It is either complete or only partial; the former case  occurs
in hollow organs—for example, in the  rectum, in the prolapsed and
inverted womb.  At an external  opening of the  body intussusception 
ANOMALIES OF CONNECTION.
59
becomes prolapsus, which is intussusception minus the external layer or
sheath.
  3. Protrusion, propendentia, of viscera, owing  to  congenital fissure,
or to rupture or penetrating wounds  of the parietes of cavities.
  Again, the position of organs may be anomalous, independently of any
change  of place, simply  by preternatural inclination,  especially in the
shape of obliquity.   This species  of deviation is sometimes primitive and
congenital,  sometimes acquired.   It  affects  the eye,  the  heart,  the
stomach, the uterus,  the  teeth, &c.   It is  frequently coupled with  obli-
quity of form, as in the case of the uterus.
                          CHAPTER  V.

                   ANOMALIES OF CONNECTION.

   These anomalies (vitia nexus) consist in diminution  or  total absence,
or else in enhancement of the natural connection and contiguity of organs.
They are both primitive and acquired, and, in either case,  exceedingly
various in degree and extent.  To the former belong the opposite  ex-
tremes of cleft-formation, and of malformation from fusion, together with
atresia.
   1.  Cleft-formations.
   (a.) A considerable  number  of these have their foundation in  the
germ being  originally a membranous expansion, the  edges of which
incline towards each other, eventually meet, and thus form into cavities
or cylinders.
  The two  cavities developed out of the  animal layer of  the germ,  for
the inclosure  of the  central  nervous system and of the  organs of  the
neck, the thorax, and the abdomen, are formed out of the union of  the
so-termed abdominal and visceral plates.   Now, supposing the union of
the edges of these plates not to take place at all, or to take place  but
imperfectly;  or supposing  consummated  union to become  redissolved
through some agency, like the accumulation of watery fluid; there would
result, either anteriorly  or  posteriorly, and commonly at  the median
line, although  often elsewhere, a cleft or gap, attended by prolapse, or
even by destruction of the implicated viscera.
  Clefts of this kind are :—
       Cleft skull (hemicephalia).
       Cleft spine (spina bifida).
       Cleft countenance.
       Cleft cheek.
       Cleft palate.
       Cleft upper-lip.
       Cleft tongue.
       Cleft in the thorax.
       Cleft in the abdomen.
       Cleft in the pelvis. 
60
ANOMALIES  OF  CONNECTION.
       Cleft urinary bladder, so termed prolapsus, inversio vesicae.
       Cleft dorsum penis (epispadiasis).
  The last two are generally combined with cleft pelvis.
  The intestinal canal is in like manner developed out of an expansive
formation, the united vascular and vegetative layers of the germ, by the
approximation  of  its edges, out of a  groove  in  front  of the  vertebral
column.  Hence, clefts occur in the intestinal  canal, in the stomach, as
arrested growths.
  (b.)  Other clefts, besides those mentioned, originate in the gaps which
occur during the normal development  of particular  parts, not closed at
the proper time.   To these belong:
  Cleft choroid membrane  and iris (coloboma iridis).   In the embryos
of all vertebrata we meet, at an  early period,  at the inner, lower angle
of the eye, with  a  narrow  colorless  stripe in the choroid membrane,
which commonly disappears before the iris becomes developed. ^  When
this stripe continues beyond this period, it often  abides  in  the iris, and
is perceptible after birth.
  Cleft at the  side of the neck, congenital fistula of the neck, founded
in the mode of development of the visceral cavity of the head.   The vis-
ceral edges of  the animal layer of the  germ do not grow towards  each
other in continuity,  but in ridges, termed visceral or branchial arches,
which are parted by fissures, termed visceral or branchial clefts.  When
the early closure of these does  not take place, occasion is given to the
somewhat rare malformation in question.
   Cleft urethra and scrotum (hypospadiasis) of various grades.  At an
early period is discoverable, at the lower side of the  rudiment  of the
penis,  a groove, which extends to the  common orifice of the urinary and
sexual organs.  In the male, the edges of this  groove being brought into
apposition, coalesce into a  raphe or  suture, and thus form at once the
scrotum and the urethra.  Where this process wholly or partially fails,
there arises a malformation which, if the penis be at the same time short
and the testicles retained within the abdomen, simulates female develop-
ment—a form of spurious hermaphroditism.
   To this malformation succeeds—
   Cloacal formation, junction of the orifice of the anus and of the external
orifice of the urinary and sexual organs—a formation which, being at an
early period  normal, may,  through an  arrest of development, become
persistent.   In the  male it is necessarily associated with  the  last-men-
tioned vice of formation, that is, with hypospadiasis, frequently also with
cryptorchism.
   (<?.) As cleft-formations may likewise be reckoned the  persistence of
certain communicating apertures between parts which, at a later period,
ought to remain separate, as also the  abiding  patency of certain canals,
namely:
   Befective development of the septa of the heart's ventricles and auricles;
permanent patency of the foramen ovale.  These septa form only gra-
 dually within the  heart, the septum of the auricles not arriving at its full
 development until after birth.   Defective development of the septum of
 the ventricles occasions a resemblance with the hearts of fishes and of
 reptiles (the crocodile excepted), and especially of serpents and tortoises; 
ANOMALIES  OF  CONNECTION.
61
absence of the septum of the auricles a resemblance, in particular, with
the hearts of fishes.   It is often quite evident that the arrest of develop-
ment has been caused by endocarditic changes in the valves—the residue
of foetal valvular inflammation.
   Abiding patency of the ductus arteriosus, ulterior dilatation thereof.
   Abiding patency  of the ductus venosus Arantii, giving rise to the
abduction of a portion of blood from the vena portae into the vena cava.
   Abiding patency of the processus vaginalis peritonei (the upper por-
tion of the tunica vaginalis testis), so commonly the cause of congenital
hernia  or  hydrocele.  Generally speaking, the inguinal  canal closes
immediately after the testis has, in the seventh month, descended into the
scrotal sac, carrying with it a process or continuation of the peritonaeum.
Occasionally an  arrest of development prevents the  said  closure  from
taking place.
   Abiding patency  of the urachus,  allowing the escape of urine through
the umbilicus.  Urachus and  urinary bladder  are  the portions of the
allantois internal to the  embryo, which is destined to convey the umbili-
cal vessels from the embryo to the external  membrane  of  the ovum
(chorion), for the formation of the placenta.  The portion of  the allan-
tois external to the umbilicus becomes obliterated at  an  early period.
 Of the internal remnant the inferior portion becomes developed into the
urinary bladder, whilst the portion intervening between that and the
umbilicus, contracts into a cord, the urachus.
   Cleft member (schistomelus) commonly appears from between the third
and fourth fingers or toes to the wrist or ankle.  It is probably derived
from external causes, and, as Gurlt infers from an examination of the
foetus of a dog, from adhesion to the amnion.
   2.  Malformations through fusion (symphysis).  To these belong:
   (a.) Cyclopia.  In this malformation we find in the forehead a single
eye, or the two eyes blended into one.  It is met with under every gra-
dation of the fusion of both eyes.  The nose is  either wanting, or defec-
tive,  being  frequently  represented by  an  imperforate  proboscis-like
appendix,  which overhangs the one  eye or the two united.  The mouth
is sometimes normal, sometimes misshapen—nay, the entire infra-frontal
countenance may be wanting.  The ethmoid, nasal, lachrymal, turbinated
bones, the vomer, the superior maxillary and palatine bones,  the ptery-
goid  processes, are  often  all or severally absent; the  anterior  lobes of
the brain  invariably  so.   One  explanation  of this deformity is based
upon Huschke's hypothesis, of both eyes being  developed out of  a single
primitive rudiment,  subsequently divided in twain by the interposition of
the nasal and facial parts.  An arrest in the development of these parts
might then, indeed, suffice to occasion the mischief.   Bischoff, however,
firmly maintains that the two eyes  originate at once,  distinct  and  sepa-
rate, from the anterior primitive brain-cell, and he derives  the cyclopian
deformity  from an arrest in the development of this cell causing the too
close approximation and  eventual  fusion of the rudiments of the two
eyes.   As this defective development of the brain-cell frequently causes
a defective development of the  anterior portion of the plastic material
for the  chorda dorsalis, and often  for the  anterior process of  the first 
62
ANOMALIES  OF  CONNECTION.
visceral arch, it would thus  occasion the absence, before alluded to, of
the aforesaid facial bones.
   (c.)  Monotia, agnathus, otocephalus.   The two ears  approach each
other more or less below the skull, and finally coalesce.^  The inferior
maxilla is wanting.  The superior maxillary, the zygomatic, the palatine
bones, along with the pterygoid  processes, are either, in like manner,
wanting, or else inadequately developed.  The mouth is absent or very
diminutive.  The skull is normal,  but the face small, and in brutes pro-
jects after the fashion of a proboscis.   Bischoff considers this deformity
referable  to  an arrest of development of the first visceral  arch, inter-
cepting or impairing the growth of all the said bones, and thus promot-
ing the mutual approximation of the two ears beneath the skull.  Were
the internal organs of  hearing implicated, the source would needs reside
in a defective development of the third primitive brain-cell.
   (d.) Monopodia, M.  Syrenomeles,—Siren-malformation.   The  two
lower extremities, more or less perfectly developed as to their individual
parts, are blended into a single one.  The pelvis, the sexual and urinary
organs, are wanting or imperfect; the intestinal canal is defective beyond
the caecum, and the anus  invariably absent.   The  extremities,  more-
over, have revolved upon their axes, the direction of the patella  and of
the poples of the knee being reversed.   It is founded in a faulty deve-
lopment of the lower end of the trunk and of its organs, the rudiments
of which  approximate too  closely towards each  other,  and ultimately
coalesce.
   Syndactylus, aschysto-dactylus.  Here the fingers or toes are imper-
fectly separated.   It is an arrest of development, the rudiment of hand
and  foot,  even when distinctly  cognizable, not manifesting at first any
division of fingers and toes.
   (e.)  Fusion  of  kidneys,  testicles,  and  ovaries.  This, according  to
Bischoff, is not due to arrest of development,—even  these  organs not
originating from a single rudiment,—but rather to a defective develop-
ment of the intermediate formations occasioning fusion of the rudiments.
   3.  Atresice.
   (a.) Atresia palpebrarum.  The eyelids are said to coalesce naturally
towards the end of the third or the commencement of the fourth month,
and to separate afterwards.   Accordingly this malformation  would be
an arrest  of development.
   (b.)  Atresia oris.  According to Burdach, the lips  coalesce  in the
fourth month, closing the mouth until the sixth, when they again sepa-
rate.   According to Bischoff, however, this malformation might have a
different origin.  At a very early period, namely, the visceral edges of
the animal layer mutually incline towards each other inferiorly, unite,
and  form, through  the  medium of  Rathke's so-called  inferior  bond-
membrane, the visceral cavity of  the  embryo.  Not  until the visceral
arches  break forth above, does the upper portal to the  nutritive canal
open, and not until still later the mouth.   The  atresy might, therefore,
depend upon the abiding of the  bond-membrane.  In  either case it
would be an arrest of development.
   (c.)  Atresia pupillce.  Until the seventh month the pupil  is closed by
the membrana  pupillaris, the anterior section of a vascular sac in which 
ANOMALIES  OF  CONNECTION.
63
 the  lens, with its capsule, is inclosed.   Its persistence determines the
 atresy.
   (d.) Atresia nasi.  According to Burdach, the nostril becomes closed
 during the fifth week by a saccular  plug, which  gradually disappears
 during the fifth month.   Its persistence would occasion the atresy.
   (e.) Atresia auris externce.   The external meatus auditorius is deve-
 loped out of the posterior upper portion of the  first visceral  fissure.
 Previously  to birth  it is upon the whole  little developed.   A slight
 anomaly of formation may give rise to its closure, although at no period
 is the latter normal.
   (/.) Atresia ani.   The anus  is not  present  at  first, even where the
 terminal intestine  has formed.   A  stand-still at this  period, however,
 would involve the simultaneous closure of the urinary and sexual organs,
 seeing that their external  orifices are all developed  out of  the  primitive
 orifice of the terminal intestine,—the  cloaca.  Where, therefore,  the
 anus is alone  closed, the mischief must date from a later period, namely,
 after the separation adverted to has  already taken place.  Some phy-
 siologists believe it to be, at a certain epoch, the natural condition.
   (g.) Atresia vulvce.  Probably conditional upon  the turgescent edges
 of the  external orifice of the  uro-genital  canal  being brought  into
 apposition,  and coalescing  in the  female, as they ordinarily do only in
 the  male sex, for the formation of the scrotum.   Where the  anus is at
 the  same time  deficient, we  have here  again non-development  of  the
 cloacal outlet.
   (h.) Atresia vagince, frequently due to a preternaturally large hymen,
 although occasionally to a partial deficiency thereof, causing  two blind
 sacs to overlap and compress each other.
   (i.) Atresia uteri, not being derivable  from the mode of development
 of the uterus, is to be regarded as a vice of formation, or else  as  the
 result of inflammation.
   (k.) Atresia urethrce, in the  male, an arrest of development,—the
 groove at the nether part of the penis, out of which the urethra is deve-
 loped, not  extending to  the glans..   In the fourth  month the glans
 becomes perforated, in the natural course:  if this  process be checked,
 this  part will remain imperforate.
   To acquired anomalies of connection belong, firstly, actual  interrup-
 tions of  continuity, together with their not  invariable but  frequent and
 obvious  associate, diastasis,—that is, the  parting, through loosening or
 lesion of continuity  of the binding material of two bones immovably
 connected together, and again  the estrangement and deviation  of  the
 articular  ends of two bones,—luxation.   Secondly, agglutination  and
concrescence of two or more formations originally contiguous, or brought
by accident or design into mutual association, and abiding  contact with
one another.  Agglutination is effected through the  binding property of
recently  exuded fibrin;—concrescence  through the  medium of textures
newly formed out of exuded  protein substances,  and  like  unto   the
normal textures,  for example, areolar  tissue; or through the modium of
such as differ in certain respects, for instance, in the degree of density
of aggregation,—in the arrangement of their form-elements,—in  chemi-
cal composition,—cancer, for example,—and, lastly,  through the medium 
64
ANOMALIES  OF  COLOR.
of vessels.   This species  of  concrescence, in accordance with the cha-
racter of the binding  material, is effected  by loose, filamentous adhe-
sions, admitting of  a certain  degree of motion in the affected  organs;
or by tense and intimate conglutinations.
   The adhesion of the parietes of hollow organs, and the  obliteration
of canals and of their mouths, represent acquired morbid atresy.  This
originates in various ways: for example, in concentric  atrophy  conse-
quent upon deficient expansive power.   Thus, in  ducts, it follows the
extinction of the gland;  in  bloodvessels, the cutting off of the blood
stream; or it is the effect of  abiding compression and mutual contact of
the parietes;  or,  again,  it  may  be the  result of the deposition of
organic matter  out of the contents of the canal, or  of textural  changes
in its walls, produced  by  inflammation, cicatrization, and the like; or,
lastly, of luxuriating heterologous growths.
   The coalition of the two bones in mutual contact within  an articula-
tion is specially termed articular adhesion, anchylosis.
                         CHAPTER VI.

                      ANOMALIES OF COLOR.

  Anomalies in the  color of organs are  either  essentially conjoined
with or independent of change of  texture.  Our concern here is princi-
pally with  the  latter kind.  We  shall content ourselves with a simple
allusion to  the former, as the  true  pathological production  of pigment
will be separately discussed in the sequel.
  The said anomalies consist in diminution, in augmented depth, or in
altered quality, alienation,  of  color.  They affect the totality, or simply
the majority of textures  and  organs, or,  again, individual organs  only,
or mere circumscribed portions of these latter.   Their causes, it will
immediately appear, are numerous.
  Diminished coloration is sometimes  primitive; various organs, owing
to an  arrest of development, not acquiring their natural amount of
color, a condition very commonly associated with the defective develop-
ment of the organs in respect both of texture  and of bulk, as in the
instance of muscles.  We may  specify  a  well-known species  of this
anomaly,  namely  albinoism  (leukaethiopia,  leukopathia),  wherein the
pigment is wanting in the rete mucosum of  Malpighi, in the hair, in the
iris, and in the choroid membrane of the  eye.
  It is, however, more frequent as an acquired morbid condition—in a
word, as decoloration, blanching.   Under this head are to be reckoned,
firstly, the pallor of texture consequent upon anaemia, or upon changes
suffered in various dyscrases, as chlorosis, albuminosis, dropsy, tabescent
diseases, by those carriers of coloring  matter, the blood-corpuscles;
secondly, the blanching of textures produced by their maceration in the
serum  of dropsy, by atrophy, by fatty degeneration, the muscles  being 
ANOMALIES  OF  COLOR.
65
here the organs principally affected; lastly, that for the most part local,
gradual, or rapid decoloration, due, in the former case, to cessation of
the development of  pigment, in the latter to rapid withdrawal, or more
probably to destruction, by some unknown  means, of the existing  pig-
ment.   As an example  we may cite  the topical  blanching  of  the
common integuments  in colored tribes, in  parts rich in pigment  (the
scrotum) in whites, the progressive or sudden hoariness of the hair,  &c.
  Augmented  or  deepened coloration is, in certain colored textures,  in
the animal muscles, for instance, the consequence of  and the attendant
upon hypertrophy.  In the outer integuments, it is conditional upon the
excessive  development of pigment in the rete mucosum;  in scars,  as a
purple  tint, caused by the  capillary vessels appearing through the tex-
ture of the cicatrix, in the embryonic stage, with its thin layer of epi-
dermis.  It is usually  a consequence:
  (a.)  Of  hyperaemia  (congestion) and stasis, more especially where the
blood is dark-colored,  as in cyanosis, in asphyxia, in a typhous crasis, in
an inspissated condition of the  blood, consequent upon loss of serum, &c.
   (b.)  Secondly, of  hemorrhage, extravasation of substantive blood into
textures (apoplexy);  sugillation or  suffusion founded in rupture, which
latter  may be the consequence either of traumatic  influences,  such  as
contusion and concussion, or of excessive hyperaemia, mechanically pro-
duced ; of blood  stasis;  of  disease of bloodvessels;  or else the conse-
quence of the  patency of bloodvessels, engendered by the liquefaction,
the breaking down of  textures.
   (c.)  Finally, of the  exudation of blood-serum, with an appendage,  so
to speak,  of blood-pigment—to which category belong ecchymosis, pete-
chias in decomposition of the blood, in scurvy, in putrid typhus, in acute
exanthematous decomposition,  in acute alcohol dyscrasis (the scurvy of
drunkards), &c.  As subordinate to this we may also mention those out-
ward signs of death which assume essentially the guise of red coloring,
namely, death patches, death livor, spurious sugillations.   Their charac-
ter varies :
  1. They are  dependent upon local  hyperaemia and stasis,  brought
about  during  the  death-struggle and the period immediately following
death,  as the consequence of unequable palsy of the small and capillary
vessels,—whence it arises that the blood accumulates in distinct  patches
of the capillary system various in extent, whilst in others, owing to the
continued contractility of those vessels, it is  urged onward into the veins.
Hence they consist in  injection, and, where the usual  accompaniment  of
the livor, from  imbibition, is wanting, they are for the  most part  marked
by being sharply bounded by a blanched texture.  They are particularly
frequent in the mucous membrane of  the  intestinal  tract, and in the
lungs.
  2.  Other death-patches originate after death,  being the result of ca-
daverous hyperaemia or hypostasis, which signifies the descent of the
blood  within the vessels, conformably with the laws  of  gravitation, to
the most  dependent parts.   These  patches are  mostly of great extent,
deeply  saturated at their most dependent parts, and less  and less so
higher up.   Their seat, answering to the usually supine position of the
dead body, is the occiput, the posterior  part  of the  trunk  and limbs;
  VOL. I.                           5 
66
ANOMALIES OF COLOR.
and it includes, not alone the common integuments, but also the subcu-
taneous soft  parts, and even the posterior portions  of  the  viscera con-
tained in the great  cavities.  Under difierent circumstances, they affect
other regions of the body;  in a lateral position of the corpse, the nether
lateral half of the organs—for example, in hemi-lateral hyperaemia, the
one  hemisphere of the brain; in the prone  position they appear in the
front;  in those hung by the neck, at the lower half of the subject and
internally, in the  organs of the pelvis and hypogastrium.
  They are the more developed the greater the amount  of blood and the
smaller  the degree of coagulation which  the  previous illness and the
mode of death have produced in the blood during the  mortal  struggle.
Accordingly, after  acute or  chronic decomposition of the fibrine in the
blood, after asphyxia, they are especially marked by their rapid develop-
ment after death, by their  extent, and by their depth of color.
  3. A third  species of  death-marks arises  from the imbibition, by the
coats of bloodvessels, and the transuding from  thence into the neighbor-
ing tissues, of blood-serum, which, owing to decomposition, has taken up
a portion of the pigment of the blood-globules.   In this manner are pro-
duced the livid striro which follow the course of  the subcutaneous veins
in the common integuments, the red coloration of the endocardium, and
of the internal membranous strata of the vascular  trunks, the diffuse
reddening of serous and mucous membranes, the red tinge observed in
parenchymata and seemingly inherent in their  textures.  Not only does
imbibition  pass from one organ to others  contiguous,—even fluids, con-
tained within hollow organs, as also in muco-membranous canals and in
serous sacs, receive the blood-tinged serum,  thereby acquiring the same
cadaverous hue; or, again, the blood-tinged  serum is  found in the said
cavities, pure, and unmingled with pre-existing fluids in  the form of
cadaverous exudations.
  The reddening of imbibition is, of course, most readily derived from
vessels,  the seat of  hyperaemia  and  of stasis;  therefore very commonly
from the death-patches of the two species above named.  The redness of
injection characteristic  of  hyperaemia and stasis merges in, or becomes
masked and disguised by, that of imbibition.
  Death-spots of this kind are marked by absence of injection;  by the
obvious  cause, namely, blood being discoverable at the point of the deep-
est saturation, and by the stain being washed out towards the circumference.
  Where the previous disease involves liquefaction of the blood-plasma—
they are rapidly developed, and they increase in saturation and extent in
proportion as, favored by various external  influences, cadaverous decom-
position gains ground.
  It would appear, from  the  above, that death-spots  are, for the most
part, stains resulting from  a combination of hyperaemia with imbibition.
  Amongst the number of  imbibition stains, with the character of death-
marks, is to be reckoned the  yellow  tinge imparted to the membranes of
the gall-bladder and of  the adjacent membranes of the stomach and in-
testine by the imbibition of bile.
  To qualitative alienations of color belong more especially, as  cadaveric
stains subordinate to the above—
  1. The original  changes of  tone  in  death-stains to blue, purple and
violet, dependent  upon the  blood-crasis. 
ANOMALIES  OF  COLOR.
67
  2. The brownish and greenish tints, and the dark green dye developed
out of  the reddening of imbibition, both in the common integuments and
in other  soft parts,  as also in an especial manner in the intestinal mem-
branes and their  contiguous  formations—namely,  the peritoneum, the
areolar, adipose, and muscular tissues, and the liver.  These varieties of
color are produced by certain gases—hydrosulphuric acid and  sulphide
of ammonia,—evolved  in  the abdominal  cavity, and within the tissues
themselves.  These  gases react thus upon the red pigment of the blood
within the tissues  generally, and in the muscles most of all.
  3. The dark  brown,  black, green, and ink-black discoloration of the
spleen, from its fissured surface to various depths, as also of the ramifi-
cation  of bloodvessels in the fluid sac of the stomach from the imbibition
of gastric juice.
  4. The more rare violet-red, iodine-colored, diffuse lividity of the intes-
tinal membranes.
  Other preternatural  colorations, for the most  part equally cognizable
in the  living body, are, in particular—
   1. The deep red  tinge characteristic of thin  watery blood, as also of
all the tissues, down to the common integuments, in cases of poisoning
with carbonic oxide and carbonic acid gas.
   2. The copper-red tint of  the  skin in venereal stains, and in the cir-
cumference of venereal ulcers and skin eruptions.
   3. The diffuse sallowness, and the circumscribed freckle-spots, termed
liver-stains or ephelides, in cachexia.
   4. The violet hue of typhous hyperaemia and stasis.
   5. The greenish and yellowish tones of sugillation of the common in-
teguments,  arising from deep-seated extravasation of blood.
  6. The yellow tinge of the solids and fluids, assuming manifold shades,
the most intense of which are a brazen- and a greenish-yellow, engendered
by the coloring  matter  of the bile, where the secretion and excretion of
that fluid are intercepted, or where bile mingles with the blood,  as in the
typhous  crasis.   It is frequently superinduced  by pyaemia,  and occurs
as the  substantive and essential dyscrasy in yellow atrophy of the liver,
and probably in  yellow fever.   As  this  pigment  generally associates
itself with  the  exsuding plasma, the majority of the soft  parts, more
especially the vascular and succulent—the secretions and incidental pro-
ducts of inflammation—are all dyed yellow.
  7. The rust-yellow, rust-brown, black-brown, and black tints of cer-
tain organs, resulting from a  corresponding granular pigment, partly
contained within  pigment-cells—a formation, which will, in the sequel,
be considered more at large.
  8. In conclusion,  those anomalous  dyes, produced by the assimilation
of pigments, or of substances which, either with or without the interven-
tion of some specific influence—light, for example—enter into peculiarly
tinged  combinations with animal tissues.  As instances of the decolora-
tion of both fluids and solids, we may cite the yellow appearance of the
urine from the ingestion of rhubarb, the reddening of the  bones from
feeding upon the root of rubia tinctorum, the yellowness of the  skin and
of the mucous  membranes produced by  nitric  acid, the swarthy com-
plexion which follows the internal use of nitrate  of silver. 
68
ANOMALIES OF CONSISTENCE.
                        CHAPTER VII.

                   ANOMALIES OF CONSISTENCE.

  Consistence [the normal degree of mutual cohesion and of resisting
power pertaining to the elements  constituting a texture] is  either aug-
mented or diminished.   In either case the gradations and also the forms
vary greatly, cannot be  estimated but in relation to  the amount of
mechanical violence exerted, and exist, to a certain extent, in combina-
tion with each other.
  Diminution of consistence is based upon—
  1. Loosening of the mutual cohesion between the form-elements com-
posing a texture,  through  the  interposition  of  a fluid or solidified sub-
stance.   Instances are  afforded  in the loosening of texture  through
serous effusion  (dropsy), and, in hyperaemia  and inflammation, through
their products.   Such  loosening of texture is generally considerable in
proportion to the rapidity with which the said products form.
  2. Atrophy,  both primary and secondary, provided the density of the
texture be diminished.
  3. Liquefaction and  breaking down  of the elementary forms of the
texture, as in suppuration, in gangrene, but  most especially and most
variously  in  liquid exudation from mucous membranes, which by its
chemical properties proves destructive to  the  underlayer.  Liquefaction
of the substance  of the  liver, through anomalous or intercepted bile,
offers another instance in point.
  4. Next to these rank the softenings of certain organs, particularly
of the mucous  membrane lining the stomach, of the lungs, and of the
brain, brought about by the resolvent agency upon  the textures of a free
acid.   They represent those processes to which,  in  conjunction, perhaps,
with the foregoing, the term softening ought properly to be restricted.
  The abstraction of earthy salts from the bones, in rickets and osteo-
malacia, belongs to this class.
  5. It is brought about by a transformation of textures, the nature of
which is most probably a breaking  up, with conversion of the chemical
constituents;—for example, the breaking  up of the primitive muscular
fibrils, or of the texture of the  annulo-fibrous tunic of the arteries, in
fatty degeneration.
  Diminished consistency manifests itself as irregular softening, com-
pressibility, lacerability, maceration, liquefaction,  and solution; or else
as pulpiness,  putrescence, friability, fragility—the  latter property being
frequent in the osseous  system, in muscles, and  in the annulo-fibrous
tunic of the arteries.
  Increase of consistence varies, in like manner, as to its character and
cause.   It is based—
  1. Upon diminution of the humecting plasma, by which the texture is
pervaded  (water).
  2. Upon hypertrophy.   Those  augmentations of consistence are par- 
SEPARATIONS  OF  CONTINUITY.
69
ticularly marked which depend upon true hypertrophy without increase
of volume, and upon various kinds of spurious hypertrophy.
  3. Upon atrophy, the reduction of volume being here accompanied by
condensation,—concentrical hypertrophy,—of the brain, for instance.
  4. Upon inflammation,—through the solidification and textural trans-
formation of coagulable products;—in other words, by the issue of the
inflammation in induration.
  5. Upon what is termed ossification, so common  in the aforesaid pro-
ducts of inflammation.
  Increase  of consistence manifests  itself as preternatural toughness,
hardness, rigidity.   Relatively to the  normal condition of the textures,
it often appears  less in the shape of absolute increase,  than of a change
in the character of the consistence.  Thus the friable liver, the kidneys,
under  certain conditions,  in  spanaemia, for example,  toughen through
defibrination of  the sanguineous  fluid.   The  increase  of consistence is
often,  moreover, but a seeming one, and  even such  only with certain re-
strictions.   Thus  the organ concerned will exercise,  against ordinary
external influences, a resistance exceeding the natural, and yet be power-
less against more forcible  impressions, because, although with increased
density it has become harder and firmer, it has at the  same time lost its
toughness, and become morbidly fragile  and brittle.   Muscle affords an
example.
                        CHAPTER  VIII.

                  SEPARATIONS OF CONTINUITY.

  They are engendered either by external and especially by mechanical
influences, or else by various internal causes which may, in like manner,
operate mechanically.
  To the former belong:
  1.  Simple or complicated injuries from penetrating  mechanical vio-
lence, with or  without loss of  substance ;—incised, punctured, contused,
gunshot,  bitten, and lacerated wounds;—solutions of  continuity occa-
sioned by fire and cautery.
  2. Imperfect and complete laceration and rupture of solid as also of
hollow organs, consequent upon concussive violence,—especially when in
the condition of repletion and of distension,—lesions of continuity fre-
quently unaccompanied  by perceptible  injury to the  common  integu-
ments and to the  parietes of the implicated cavities of the  body.  The
casting of the  envelopes of particular organs caused by similar violence,
as the separation  of periosteum, of the dura mater, from bone, of  the
fibrous capsules (tunicae albugineae) of certain viscera, as of the spleen or
kidneys,—is of like significance.
  3.  Simple and complicated  fractures  of bones, incurvation  of soft,
rickety bones,  casting of the epiphyses.
  Separations of continuity from internal causes are dependent upon 
70
ANOMALIES OF  TEXTURE.
various contingencies.  Where mechanical influence is simultaneously at
work, the two influences co-operate in  such wise that where the one pre-
dominates, less of the other suffices to produce the effect.   Their occur-
rence may be rapid or slow.  They are brought about—
  1. By violent exercise  of the  voluntary  and involuntary  muscles,
lacerating either these  or their tendons, or even  affecting the bones,—
in convulsions, for instance.
  2. By excessive distensions of hollow organs, as in laceration of the
intestine,  of the  urinary bladder  from  accumulation  of its  contents
through paralysis, through mechanical obstruction, stricture, closure, &c.
  3. By hemorrhage.   Here the lesio continui consists  in great lacera-
tion,  contusion,  disruption,  destruction of texture; take, for example,
apoplexy of the brain, of the liver, of the muscles; the forcible separa-
tion of the strata composing a  membranous organ ;  the loosening of the
enveloping membrane of organs, of the periosteum from bone, of the
tunica albuginea, through extravasated blood.
  4. By atrophy.  When favored by a mechanical influence it occasions
a rapid lesion of continuity in  the shape of laceration,—or  else, being
itself caused by pressure  and tension, it serves in the long run to pro-
duce lesion of  continuity, more especially  in the muscles and nerves.
Under this head should be mentioned the spontaneous casting  of normal
and of morbid  formations, owing to defective nutrition, as of the hair,
the nails, the teeth, horny excrescences, and the like.
  5. Separation of continuity  is  the final result  of high  degrees  of
diminution of consistency, especially in true softening, the consequence
of textural disease.   If, therefore,  any mechanical cause be requisite  at
all,  the slightest,—even the degree ordinarily in operation, as for exam-
ple, repletion of a hollow organ, suffices to produce the effect.   Amongst
textural  diseases, inflammation—from  its  effects  in  the loosening  of
tissues,—and the fatty degeneration of muscular organs, more especially
of the annulo-fibrous tunic of arteries—stand pre-eminent.
  6. In fine, lesions of continuity are engendered in primary textures,
as well as in new growths, by various processes of liquefaction and disso-
lution, especially by suppuration and gangrene.   To this  head belongs,
amongst others,  the spontaneous separation of dead parts, for  instance  of
fingers, of entire limbs, of heterologous products, such as fibroid and
cancerous growths.  Lesions of continuity are, upon the  whole, simple,
or else more or less associated with loss  of substance.   Their cure is
effected by the  immediate union of the edges or surfaces of the wound,
or,  in the case last alluded to, by regeneration.
                         CHAPTER IX.

                    ANOMALIES OF  TEXTURE.

  These are the most  important of all.   They affect the solids and the
fluids, especially the blood, in so far  as certain form-elements enter as 
ANOMALIES  OF  TEXTURE.
71
essential ingredients into its composition, and  so far  as this general
source of nutrition, under particular circumstances, contains and supplies
formative matter anomalous  in many respects  as to  its embryonic cha-
racter and primitive forms, and also as to all its  ulterior stages of  deve-
lopment.   They are commonly connected, in the relation either of  cause
or of effect, with various other of the anomalies  of volume, of consistence,
of form and of color already discussed.
   Every change of texture being founded in an anomaly of general nu-
trition, the proximate causes of this anomaly have to be investigated.
   As such are directly demonstrable or at least deducible from analogy,
—alterations of the blood, as the general fluid of nutrition, and anoma-
lous character of the nutritive process itself.  Accordingly, textural
disease of the  solids is in the one case the reflex of constitutional disease,
in the other case a mere local ailment.
   Quantitative anomalies of nutrition  having been considered under the
heads  of hypertrophy and  atrophy, the present chapter will  comprise
those textural diseases alone which depend upon qualitative anomalies of
nutrition.
   Textural diseases may be primitive arrests in the development of the
texture—for example, in bones, in muscles, in pigment,—such as we may
observe at any time in tissues adapted for regeneration.   The majority
are, however, acquired during intra-uterine, and  more especially during
extra-uterine  life.   In  the former case the textural anomaly is con-
genital.
   Textural anomalies manifest themselves—
   1.  As new growths.   The most numerous of the class.
   2.  As a breaking down of texture.  The disruption involves both the
primitive  physiological  and the new-formed pathological texture,—the
latter, by their frequent persistence, at the embryonic stage of textural
development, or even in  the condition of  the  primitive  rude  blastema,
are particularly predisposed to this sort of conversion of their  elements.
To this subdivision belong, besides the reduction of textures in atrophy—
besides the breaking up of textures in genuine  softening, in particular
the liquefaction of textures in various  processes of exudation,  in suppu-
ration, and in  gangrene.   And to these are yet to be added other pro-
cesses which seem to be conversions of various  complex  substances con-
stituting, now  a rude blastema, now a definite texture,—the  breaking
up of  fibrinous, albuminous blastemata, of muscular fibrils, of yellow
artery-fibres, with conversion of their elements into fat, &c.  They will
be considered, together with their attendant  circumstances, under the
heads partly of general, partly of special anatomy.
   New growths, as already observed,  furnish forth the great  majority
of textural affections.  For, apart from their  mere local characters,
almost all constitutional diseases  are  prone to localization and to the
deposition, within an area more or less defined, of products in the shape
of blastemata.  Even the processes of liquefaction are in part ultimately
reducible  to a new growth, for  example, to an exudation destructive of
the texture, to the production of acid, &c.  Textural diseases  assuming
the shape of new growths were formerly distinguished in a manner which
here calls for a few remarks.  Pathologists discriminated between  : 
72
ORGANIZED NEW GROWTHS.
  1. Changes (metamorphoses) of textures.
  2. Genuine new or heterologous growths.
  With reference  to this distinction which,  before  the  adoption of the
present auxiliary methods of research was highly estimated, we have to
observe that, strictly speaking, the conversion  of one texture into an-
other only occurs in isolated instances, which will be hereafter specified.
With these exceptions, all conversions are but seeming ones, and consist
in the anomalous  growth becoming developed betwixt  the elementary
particles and filling up the interstices of the original  normal texture, so
as to occasion the reduction and resorption of the latter.
  This  process of reduction and absorption may be so complete as ulti-
mately to cause the original texture to be altogether replaced by the
new growth, which now presents one uniform mass, corresponding in
volume  with the texture  expelled, or even exceeding it,—in  a word,
constituting a tumor.
  But although this process apparently disproves any conversion, it still
remains matter for inquiry whether, in  a certain sense, a conversion do
not take place,—whether the original but reduced texture do not, under
the determining influence of the heterologous  development, furnish the
blastema  for the new growth?  Several circumstances afford decisive
evidence of a metamorphosis of this kind.
  As true conversions are to be regarded—
  (a.)  The  ossification of cartilages intended for  permanent ones; as
also of pathological cartilage—of certain euchondromata.   Again
   (b.)  The fibrillation of the hyaline intercellular substance of cartilage.
  (c.) A metamorphosis of muscular fibre  into areolar fibrils, such as
takes place, in the organic muscles obviously through a splitting of the
muscle fibres,—in the animal  muscles,  probably through fibrillation of
the collapsed  sheaths of the primitive muscle  fibres, after  the breaking
up and resorption of their contents (the primitive fibrils).
   (d.) A transformation of  the  organic muscle-fibres  into the  annulo-
fibrous membrane-texture of arteries.
   (e.)  A transformation of primitive muscle-fibrils, of the fibrous web
upon the layers constituting  the  annulo-fibrous membrane-texture of
arteries, into free fat (see fatty degeneration).   We  are not indisposed
to believe in a conversion of  hepatic cells into the elementary cells of
medullary cancer.
   Let us, after this disquisition,  turn to the division of new growths :
   1. Into organized and organizable new growths.
   2. Into unorganized new growths.


                   I.  ORGANIZED NEW GROWTHS.

             A.  OF ORGANIZED NEW GROWTHS IN GENERAL.

   These  resemble normal textures, at least in  their elementary compo-
sition,—and very frequently in the  (secondary) arrangement of their
form-elements.  Where they appear amorphous, the character of  the
blastema  attaches to such amorphous growths.  They are occasionally
united with unorganized new formations, and  that commonly in a con- 
ORGANIZED NEW  GROWTHS.
73
secutive manner, the latter supervening upon the new growth, as in the
instance of so-termed ossification in the shape of concretion  or incrus-
tation.
  New growths  present great and important differences in relation not
alone to the form-elements—especially cell and fibre,—but also to the
secondary arrangement of these  elements into a texture.
  Nor do they differ  less widely and essentially as  to origin  and deve-
lopment.  In this respect they often, it is  true, follow the laws of cell-
formation—cytoblastema, elementary granule, nucleus, cell, fibre.   The
field, however,  is equally extensive of fibrillation out of nuclei and
granules, and especially that of the independent development of fibre
directly out of solid blastemata, intercellular substance, primitive  struc-
tureless membrane, and membranaceous  coagula.   Compare, with re-
ference to this and to what next follows, Blastemata.
   With reference to the grade of development attained by their elements,
new growths are classed, if such a classification be feasible, considering
the variety of elementary bases coexisting in  a single growth, and the
want of uniformity in their ulterior development, as follows :
   1. Such as exist in the condition of formless liquid, or  at that  phase
 of coagulation—the  consolidating  blastema.   They are  susceptible of
 further development, or they abide at this stage, many ultimately break-
 ing up.  They comprise some very malignant new growths—for example,
 tubercle.
   2. Such  as  attain to nucleus and cell-formation only,—perhaps to
 fibre or caudate cells.  They consist of isolated cells within a fluid, semi-
 fluid, intercellular substance (pus;  colloid, encephaloid substance); or,
 again, the cells  are  imbedded in  a paucity of firmer, amorphous inter-
 cellular substance, which acts as a  bond-mass.   Along with  them are
numerous nuclei and elementary granules—embryonic formations readily
broken up.  Some of the most malignant new growths  are  thus con-
stituted.
   3. Such as have their texture represented by fibres of different  kinds,
variously arranged, and arising out of cells, nuclei, elementary granules,
or directly out  of blastema.   To this class belong many quite benign,
and a few eminently  malignant formations: for example, fibrous cancer.
   4.  New growths, which, in their full  development, consist  of  fibres,
 cells, nuclei, blastema, although the disposition and the mode of develop-
ment of these  elements  may greatly vary.    They include new forma-
tions, both benign and the reverse.   The progressive development of the
form-elements  is accompanied  by  a succession  of chemical changes.
 Under every mode of development the reactions vary with every  phase,
from the primitive blastema to the completion of a texture, the difference
between the perfect texture and the primitive blastema being very marked
 indeed.
   With reference to the development of bloodvessels, new growths are
 either vascular or non-vascular.   The former present every  gradation,
 from poverty in bloodvessels to  luxuriant vascularity.   Nor does the
 number of its bloodvessels stand in any direct relation either to the bulk
 or volume  of the new growth, or to the stage of its development in other
 respects.   Accordingly, there are, on the one side, new  formations of 
74
ORGANIZED NEW  GROWTHS.
very considerable magnitude, which, devoid of all bloodvessels, vegetate
freely in the cavities of the body—for example, the frequent fibroid con-
cretions in serous cavities, certain cancers, &c.  On the other side, there
are blastems in which blood and bloodvessel-formation so predominate
that the  new  growth consists of little else.   (See Pathological Blood-
vessel-Formation.)
   With reference to their state of aggregation, new formations are either
fluid or semifluid,—for example, the plasma  containing dropsical fluids,
pus, ichor,  encephaloid fluid,  colloid,  the gelatinous  substance of col-
lonema, of areolar cancer, &c, or they are solid.
   Not long since there existed a classification of new growths, which,
though not altogether  available, is nevertheless deserving of mention—
namely, their division into homoeoplasice and heteroplasice.   The former
(according to the earlier  views of Meckel) are repetitions or imitations
of normal textures, the latter  alien to  the normal composition of the
organs and textures.   With respect to this division, it is to be observed,
that:
   (a.) The  chief argument  against the  assumption of heteroplasioe  is
afforded in the evidence recently obtained, that all new growths essen-
tially imitate normal formations, not alone in their origin, development,
and growth,  but also in their chemical composition.
   (b.)  Even  the secondary arrangement of their textural elements, that
is, their coarser  texture,  very frequently offers analogies with normal
textures.   Finally, their general aspect exhibits to the naked eye analo-
gies  which formerly served  for the basis of  certain classifications and
denominations.   Take for example the comparisons with various glandular
structures made by Abernethy and others.
   (c.)  It might appear from the above, that homoeoplasiae alone existed.
Still, in many heterologous formations the external aspect, the structure,
and even the textural elements, especially cell and fibre, differ, not only
in themselves, but in the  progress of  their  development and in their
chemical composition, so materially from the normal type, that the exist-
ence of heteroplasiae cannot be altogether rejected.   As regards the rela-
tion  of new growths to normal texture, it should be stated that,
   1. The heterologous formation lodges more or less uniformly between
the elementary parts of a  texture, the latter becoming infiltrated.   The
mass  (and commonly  the volume also) of the organ increases—false
hypertrophy.
   2. Where, on the other hand, the heterologous formation is developed
and increases from  an interstitial point, or even from an originally cir-
cumscribed infiltration, so that at its  circumference it rather displaces
than involves or embraces the elements of the affected organ, and so
that its periphery  becomes more or less  sharply defined, it forms an
individual independent heterologous mass,  termed  a tumor.
   The  distinctive  characters of the two are, however,  by no means
strongly marked.   Akin to the above division is another  almost essen-
tial to the medical practitioner, however little tenable in a scientific point
of view, namely, into benign and malignant  new growths (benign and
malignant  tumors).    The  connection  between the two  classifications
consists in this, that, with  certain exceptions,  homoeoplasiae appear to 
ORGANIZED NEW  GROWTHS.
75
and actually do answer to the  character  of  benign,  whilst a grade of
malignancy may be  predicated  of  a new  growth  proportionate to the
degree of its heterogeneous nature.   In this classification it is essential
to determine,
   1.  What constitutes a benign, what a malignant new growth ?
   2.  What are the distinctive marks of the one and the other ?
   In the first place, we would signify by malignant new growths, those
the origin and continuance of which either are essentially bound up with,
or else eventually lead to, a  definite constitutional dyscrasis, a general
disease giving rise to a peculiar  impairment of nutrition, and a multipli-
cation of specific new growths.  No new formation is, therefore, in itself
malignant, but becomes so either  through a specific, pre-existent, and
predetermining, or  through a consecutive, general dyscrasial  affection.
This is perhaps the proper explanation of  a malignant  new growth.  It
does  not  preclude  that occasional  purely local relation of a malignant
formation upon which the cure  of  the latter, spontaneous or  artificial,
often depends.   It will  be  seen that whatever else  is adduced  as an
attribute of malignant tumors ceases to be distinctive.
   (a.) It is very difficult to  recognize   a  constitutional disease as a
definite one reflected in a new growth, and to discriminate between this
and a cachexia engendered by the luxuriation and ichorous  vent  of a
new growth essentially local, and pronounced benign.   Besides, the con-
stitutional affection may as  yet be altogether wanting.   Even  where
several growths coexist of the same  character,  or rapidly succeed each
other, they need not necessarily be based upon any  general dyscrasis.
They may be simply so many mere  local occurrences.
   Certain other characteristics are  indispensable for a diagnosis, and, at
the same time, difficult to establish: for example, that—
   (b.) Benign growths are curable  by extirpation, whilst the malignant
recur at the same spot, or at other spots, or even at both.
   In opposition to  this,  it is to be urged,  that  many benignant new
growths recur after extirpation,  where the  disposition  to  them remains,
whilst, under certain conditions, many a malignant new growth does not
recur, but  enters  upon  a  spontaneous process of retrogression,  and
becomes extinct.
   (c.) Malignant new growths have a  marked tendency to draw within
their formative range—to convert  to their own similitude—contiguous
and neighboring textures.
   It is to be observed, on the other hand, first, that the most malignant
growths thrive and flourish as independent tumors upon a new-formed
vascular apparatus of their own, without  otherwise molesting the sur-
rounding textures than by forcing them from their positions ; secondly,
that where the original  normal textures merge  in  the heterologous
growth, this is brought about in the malignant,  precisely as it is in the
benignant ones—namely,  by a conversion  in the sense before  adverted
to; that is, through reduction, disintegration, and resorption of  the
normal textural elements.
   (d.) When malignant growths have attained their highest point of de-
velopment, they break up and enter upon a process of softening, which 
76
ORGANIZED NEW GROWTHS.
implicates or involves smrounding and included textures, and thus serves
to exhaust the organism.
   In connection with this process, the following subjects for consideration
suggest themselves:  namely,
   1st.  This so-called stage of metamorphosis—this breaking  up very
frequently fails to occur, even in the most malignant new growths.
   2d.  That apart from the general difficulty of establishing the epoch of
the highest development of  a new formation,  the act of breaking up
should seem a fortunate event as regards the growth  itself, which, by
virtue  of the elementary transformations thereby engendered,  becomes
deprived of its importance, and in many instances is excreted from  the
body.
   3d.  That this metamorphosis for the most part simply implies inflam-
mation terminating in ichorous degeneration, and death of the new growth.
   4th. That this destructive process frequently attacks the surrounding
textures merely in the character of suppuration, and that, as such, it may,
whether based upon a benignant or  upon a malignant new  formation,
either  exhaust the organism,  or, on the contrary, lead to a cure,—to the
expulsion of the heterologous product.
   5th. That where  a fresh  development of heterologous substance is
excited and kept up in neighboring parts  by inflammation connected with
sustained ichorous secretion, the malignancy of the growth may be at
least strongly suspected.
   (e.)  Malignant new growths are said to abound in albumen and casein;
benignant new growths, in  fibrin and gluten.
   Were such a distinction of new formations  not rendered nugatory by
the convertibility of those organic substances, it would become in a great
measure deprived of  its value by the number  and weight of the  excep-
tions,—-for example, those  of fibrinous  tubercle, of fibrous cancer,  the
composition of which  is  marked by a considerable amount of gluten,  &c.
   (/.) Homoeoplastic formations are, for the most part, benignant, hete-
roplastic growths malignant.
   Supposing such a distinction admitted, its utility would still be doubt-
ful, seeing that in a given case the decision frequently  depends  upon the
method followed in the  examination, and upon  individual opinion; and
again, that in  many new formations, homoeoplasia  and heteroplasia
coexist in various gradations.   For the more marked repetitions of nor-
mal textures, namely, areolar, cartilaginous, osseous  new growths, the
character of benignancy might indeed be predicated; whilst, on the other
hand,  certain forms of malignant fibrous cancer bear so close  a  resem-
blance to the benignant fibroid new growth as  to  set  discrimination at
nought.
   Microscopic  analysis, therefore, from which  important disclosures in
relation  to  the diagnosis of benignant and of  malignant  growths,  and
tenable grounds for the establishment of a system were expected, has in
reality thrown but an uncertain light upon the subject.
   Certain new growths are especially intended for the more or less per-
fect restitution of loss of substance, howsoever occasioned.   These rege-
nerated textures  are sometimes perfectly identical with the lost ones, in
formal and chemical composition, as also  in function; sometimes entirely 
ORGANIZED  NEW GROWTHS.
77
dissimilar.   The  latter  kind are  represented  in scar-texture, which,
again, may have an evanescent existence, as in provisional cicatrix, out
of which is developed, and which merges in, a texture  identical with the
lost one ;  as, for instance, the fibroid scar-texture that ensues upon loss
of substance in the bones of the skull; the scar-callus occurring at the
point of  a lesion of continuity in a nerve.  Or again, the cicatrix may
be permanent, consisting  throughout of a fibrous  texture  of various
degrees of perfection, in which the elements of the lost texture are never
reproduced; such is the muscular, the glandular cicatrix.
   New growths once established either sustain themselves without alte-
ration of bulk, or else wane  and shrivel in various ways, or even disap-
pear altogether.  Products of inflammation, even such as have assumed
a  textural character,  unquestionably become reabsorbed; so, in like
manner, do new growths of embryonic structure.
   Again, they liquefy under various transformations  of their  chemical
components,  or they become diseased in manifold ways.
   Finally, new growths increase.   This  increment takes place  through
juxtaposition; that is,  through the  accession of blastema upon the peri-
phery of the existing  structure.  Such is the growth of non-vascular
formations,  especially of those which do not rise  above the lowest grade
of development; as, for example, tubercle.  Or the increase takes place
through  the intussusception of  new blastema  from those bloodvessels of
the  diseased organ  which supply the new growth, or  from an  adventi-
tious vascular apparatus newly developed for the supply of the new for-
mation.   Finally, an increase of volume may be  based upon the variety
of chemical conversions attending the development of  textural  elements
out of blastema, and, in vascularized heterologous products, attending
the growth of those elements themselves.
   Growth and intrinsic development by no means keep pace with, but
rather stand  in  an inverse ratio  to, each other.  Rapidly vegetating
heterologous growths are mostly distinguished  by an embryonic structure.
   Upon  the rapidity of its growth depends, in a  great measure, the
degree of influence exercised  by  the  heterologous  product upon the
affected organ, upon its vicinity, and upon the organism generally.
   This influence, considered locally, consists  in pressure and  tension of
textures and of  entire  organs; in displacement and  extinction of tex-
tures ; consequently, in the production of pain, and in  embarrassment or
complete hindrance of function.
   The influence upon  the entire organism is sometimes deducible from
that which is local, shaping  itself differently according to the  different
seat of the  new formation.   In the instance  of heterologous products
luxuriating  by growth  and  multiplication,  this influence consists  in
causing the wasting of organic matter and of  power, or in the establish-
ment of a consecutive dyscrasial  state.  This latter may be  brought
about in a twofold manner:
   (a.) Either through the  withdrawal from the fluid of nutrition of some
particular substance employed as a  material in the heterologous structure
—as in defibrination of the blood and oedema in tubercle—in dropsy con-
sequent upon albuminuria.
   (b.) Or else in  a positive manner, namely, through reception  into the 
78
BLASTEMA.
blood and lymph of substances generated in the  interchange  of matter
that constitutes the nutritive  process  of the heterologous product, and
still more through  reception of the  heterologous matter itself, in the
shape  of intercellular substance, or  of elementary cells, and the like.
This directly leads to contamination of the fluid of nutrition, and thereby
to a dyscrasy reflecting the character of the heterologous growth.  It is
the more speedily brought about where circumstances are generally favor-
able to endosmosis or resorption, and  particularly so in the  locality of
the heterologous growth, where this latter  is  bulky or highly vascular,
or situate in organs rich in blood and lymph-vessels, where its mass (its
intercellular  substance) is more or less fluid.   It  occurs, however, in
heterologous  growths, both solid and  poor  in bloodvessels, when their
texture has become disintegrated and liquefied by hyperaemia and inflam-
mation.   To  sum  up, new growths possess  sometimes  a general, some-
times a local character.  Nay, one and the same new formation may, at
various, successive periods, acquire now the one, now the other character.
A growth, originally of general import, may in particular assume a local
one instead.
   New growths vary considerably as  to the organs and texture which
they affect by preference; each  possessing, in  this respect,  a scale of
frequency of its own.   Some  organs are pre-eminently  subject to one
particular kind of new formation.
   Certain new formations become developed  and subsist unmistakably
in concurrence; certain others never  cohabit, the  presence of the one
serving to exclude the other,—the appearance of the one arresting the
development  of the other.   Exclusiveness or repulsiveness  of this kind
is,  as might be expected, mutually evinced by new growths based upon
dyscrases of  opposite characters.   On the  other hand, new  formations
rooted  in  kindred dyscrases, do  exist confederately,  and purely local
new formations enter into every phase of combination.
   Let us now turn from the consideration of confirmed new formations to
that of their blastema and of its metamorphoses.

OF BLASTEMA AND ITS METAMORPHOSES, WITH AN ESPECIAL REFERENCE
                             TO FIBRINE.

   The blastema for pathological new growths ultimately proceeds from
the general fluid of nutrition, the plasma of the blood.   Accordingly, its
source is that out  of which all  normal  textures  are developed.  Its
bodily detection and demonstration  in  its simple, primitive  form, are,
however, mostly a matter of difficulty, except, perhaps, in cases where it
is  somewhat  copiously produced, in the train of peculiar and often
rapidly fatal processes, which may be experimentally analyzed grade for
grade,—for example, in inflammation and hyperaemia.  It exudes through
the parietes of vessels wherever  capillaries  exist, or  it appears  as an
endogenous segregation from the blood within the circulating  system.
In rarer instances, it is deposited by extravasation  out  of lacerated
vessels.
   The blastema is originally fluid, and it may either abide in this condi-
tion or solidify.  The earlier or later solidification, that is, its becoming 
BLASTEMA.
79
a fixed elementary body, and the degree  of  the  resulting density and
consistence depend mainly upon the presence  of coagulable protein, and
upon the degree of its coagulability, as also upon  the absence of those
counter-checks to  coagulation, alkalies, acids,  and certain salts.
   Rapidly solidifying blastemata, especially when products of inflamma-
tion, are very commonly termed  plastic,—improperly, however, because
coagulability of the blastema stands by no means in any direct relation
to the faculty of development.  Many blastemata, distinguished for their
coagulability, do not rise above the  lowest grade  of form-development,
and not alone do they stop at the grade marked out by the process of
coagulation, but their  ulterior tendency is to liquefy.   An  example is
afforded in tubercle.
   As a fluid, primitive blastema recently secreted is amorphous.  Sooner
or later, however,  it is marked by the development of form-elements, in
the  shape  of molecular granule, nucleus,  cell.   Solidified blastema is
either at the outset amorphous, or displays, from the moment of coagu-
lation, certain,  and, indeed, higher elementary forms,—more  especially
fibrillation.
   The blastemata are colorless, or  they assume the  tint of the plasma,
or they are of a reddish gray,—the fibrinous of various tones of yellow,
-—the albuminous, whitish, particularly when  fat  enters simultaneously
into  their composition,—or they display  various  shades of red  from
adhering blood-pigment, or from  the presence of blood-globules, &c.
   Chemically considered, all blastemata for  pathological new growths
are protein compounds, for the most part in various degrees of oxidation.
   The main conversion which the blastema undergoes is its development
into textures.  It  is capable, however, of abiding  in  its rude primitive
condition—of remaining dormant—or of breaking  up, or lastly, even of
becoming reabsorbed.
   Before we proceed to consider  these  several attributes of blastemata,
it seems desirable  for us to render ourselves familiar with the main con-
ditions for its development or non-development.
   If, participating in the current opinions  as to the conditions necessary
for the development of blastema,  we admit
   (a.) A faculty of development originally and essentially inherent in
the blastema, and inseparable from the idea conveyed by the term.
   (b.) The necessity of certain outward and general conditions, particu-
larly a mean temperature, the presence of water (moisture) and of oxygen.
   (c.)  The necessity of extant life in the textures into which the blastema
is  effused, and  a fortiori,  in the  individual.  In necrose textures no
development takes place at all.
   (d.) The necessity, in order to  become developed, that  the blastema
should abide in  close contact with the living  textures;  for beyond  this
the influence of the vital power  certainly appears to be  limited.   The
development of blastema usually commences close to the living textures,
and bulky effusions of blastema remain in a  backward state when removed
from these textures lingering either in their rude primitive condition, or
at the stage of form-development, determined by  coagulation, or lastly,
breaking up.
   (e.) The specific influence exerted by circumjacent  textures upon the
mode of development, and  upon the form of blastema.   We  know that, 
80
BLASTEMA.
 in the act of nutrition, of regeneration, even in pathological processes,
 blastema in  areolar tissue becomes developed into areolar tissue ; blas-
 tema in serous membranes  into areolar tissue, nay, even into  serous
 layers and sacs ; blastema in bone, into bone ; w^e  know that, in tumors,
 fibroid textures  often  imitate  the  texture  of  the organ; that  fibroid
 tumors of the uterus, for example, represent  the elementary forms of
 organic  muscular fibre;—that  in bones, cartilaginous new growths  are
 wont to  assume the form of enchondroma.
   All this generally admitted, the failure of such  influence does  not, as
 regards many, and the  more momentous cases, appear  satisfactorily to
 explain either the non-development  of  blastema, its tarrying in its rude
 primitive condition, its arrest at an  inferior stage of embryonic develop-
 ment, its disintegration, or its  development  to  unwonted  heterogeneous
 textures.  This becomes the more obvious  if, in relation to the  aforesaid
 conditions, we reflect:
   (a.) That, as a rule, the absence of moisture  is not absolute, and that
 it is also in other ways  conditional.
   (b.) That the absence of an adequate, general, and specific  influence
 in  the circumjacent  textures  can never be assumed directly,  but  only
 through the one-sided conclusion that, notwithstanding  the existence of
 other requirements, a blastema has failed to become  developed, a fact
 which might admit of a very different interpretation.
   Thus, to discuss a matter of the greatest importance  in the arena of
 facts, the sojourn of certain fixed blastemata,—for example, tubercle—
 in the primitive condition, is not ultimately referable  to the absence of
 moisture; the absence or  rather paucity of water depending upon  the
 high degree  of  coagulability proper to the said  blastema.   This coa-
 gulability must, however,  be inherent  in  the blastema itself.    Again,
 there are blastemata which never get beyond the  embryonic grades of
 development,—for example, the pus-blastema,  the blastema of  medul-
 lary and of colloid cancer.   Deficiency of vital  power, or of determining
 influence on the part of surrounding textures cannot, in every instance,
 furnish grounds for the non-development of blastema.   Thus we see very
 minute portions of blastema,—for instance, of tubercle—in robust indi-
 viduals,  in the closest contact,  with, nay, in  the centre,  of vigorous tex-
t tures, undeveloped.  On the other  side, in  a  very low degree of vital
 power, where one might rather expect little or no blastema to be pro-
 duced, we meet with enormous masses of it under various  forms of hete-
 rologous growths, engaged in the process of development.  The  pheno-
 menon so commonly regarded as an arrest  of  textural development,—
 founded in  deficiency  of  vital energy, of  adequate  working  power,—
 namely, fibrous callus, in the regeneration of bone,—cicatrix in muscle,
 &c,—is, we think, interpretable as  qualitative alienation, the blastemata
 not abiding at the embryonic stages of development of the textures to
 be regenerated, but forming into other textures, perfect after their kind.
   Still less is  this deficiency  calculated  to illustrate  that  qualitative
 variety in the development of blastemata, exemplified in so many  hetero-
 logous growths.  How should we therefrom  apprehend  the derivation of
 a cyst, of an areolar-carcinoma, and the like ?   How often should we not
 be driven,  instead  of  deficiency,  to assume an  equally  unintelligible 
BLASTEMA.
81
excess of power, where we find, in  textures of an  inferior  grade, new
growths developed, the elements of which belong to textures of a higher
order.
   These remarks of themselves lead to the conclusion:
   1.  That the abnormal development of  the blastemata is founded, not
in a deficiency, but in an anomaly, of determining influence.
   2.  That the different blastemata themselves, at  the outset, possess in-
dwelling  properties of their  own.   We  can have  little  hesitation  in
establishing, as a  basis of the doctrine  of new formations,  a native
anomaly in the blastemata, this being practically  demonstrable.  Such,
for example, are the various morbid relations of protein substances, and
in particular the anatomically demonstrable anomalies  in  the  constitu-
tion of fibrin in the blood itself, with which anomalies the different  exu-
dation, (as blastemata) correspond both as to form and  chemical compo-
sition.
   In this manner certain blastemata bear,  in their  primitive character
and composition, the grounds for  their non-development,—the  seeds of
their dissolution,—for example,  croupous  fibrin,—tubercle,—pus-blas-
tema.
   Other blastemata, on the contrary, possess the indwelling faculty of
development in so exalted and inextinguishable a  degree, as  to form, in
large  serous cavities, into free aggregations  of blastema  without any
abiding contact with textures—free fibroid concretions.
   Areolar new growths are so frequent, simply, in our  opinion, because
their blastemata are so frequent, and their  production  consequent upon
so many different processes of exudation.
   The blastema for animal muscular fibre appears, on  the contrary, to
exude only in the normal  process of nutrition, or where this process is
exaggerated to hypertrophy.
   It is very common  for mixed blastemata to exude.   Hence the fre-
quent coincidence, in one and the  same new formation, of such various
elementary forms, and of such different  modes of development.
   Primitive  anomalies of  blastema may be occasioned in a  twofold
manner:
   (a.) They may be rooted in a general dyscrasy of  the sanguineous
mass.  The effusion of blastema  coincides with  manifest anomaly  of
general nutrition. •  The blastema  bears the impress of dyscrasial adul-
teration.  This is  particularly the case with blastemata  deposited  in
mass  as  inflammatory products.   Indeed,  the copious production  of
blastema  in reduced, enfeebled subjects, admits of no  other conclusion
than that of a dyscrasial condition as the source  of such effusion; the
specific character of the latter being simultaneously manifested by its
obvious preference for particular organs.
   (b.)  Again, the said primitive anomalies may, where the general crasis
is  untainted, be based in an altered admixture of the plasma (the blood)
owing to local changes of innervation; or else in  an anomalous act  of
nutrition, for example, inflammation.
   In the former case, the blastema is a symptomatic manifestation of a
constitutional disease, and is of general—in the latter case it  is of mere
 VOL. I.                          6 
82
COAGULATED  FIBRIN.
local—import.   The same blastema, pus, cancer-blastema, for instance,
may, in one case, imply general, in another, local disease.
  A new growth  would, however,  be  equally of local significance if it
resulted  from a blastema  of originally normal  character  through an
anomalous determining influence on the part of the nerves  or textures,
or of an anomalous interchange of matter (resorption, &c.)
  Amongst the many causal relations, the mode of operation of which
is unknown, mechanical influences are  by no means the least frequent
originators of anomalous blastemata through local  changes of innerva-
tion and  of textural influence.
  We shall now leave this discussion,  and proceed to  an inquiry con-
cerning the metamorphoses of blastema.   Amongst these, the first rank
is taken up with the development of blastema into textures.   Here solid
blastemata, as the  groundwork of pathological new growths, present so
great a difference  from fluid, that the two must, as  far as possible, be
separately considered.
  The  latter  are all developed according to the laws of the cell theory,
whilst  the former disclose, besides a  variety  of granule and of fibro-
nucleus formations, a direct,  and, for the most part, preter-physiological
development, in various  ways, to higher elements in the shape of fibre.
  Blastemata of this description  are represented  by coagulated fibrin
and coagulated albumen.   In the identity, however, of the process of
development  in  both, fibrin  is pre-eminently adapted for experimental
study,  owing to the greater frequency of its occurrence, especially in an
aggregate and  bulky form.  Under certain  conditions,  its coagulation
alone suffices to  constitute  textural formation.   We shall, therefore, do
well to preface an inquiry into the nature of solid  blastemata  by the
study of coagulate fibrin in its relation to the doctrine of exudation and
of blood disease.

                        COAGULATED  FIBRIN.

  The  simple coagulum met with in  the  heart  or great  vessels after
death,  and in blood drawn from bloodvessels during life, furnishes the
chief groundwork for this inquiry.
  These  coagulations, which vary  essentially, both  as  to  external ap-
pearance and to elementary  constitution, form  the  basis of the different
qualitative fibrin erases.  We should, however,  begin by stating that the
individual forms seldom, if ever, occur in their perfect simplicity, owing
both to the mutable nature of the substance, and to  the fibrin not be-
coming throughout equally influenced by the  disease.   This corresponds
to the numerous exudates composed of differently constituted fibrinous
materials, as  also to the frequent impurity of blastemata in general.
  The  more important forms, described from the most perfect specimens,
are as follows:—
  1. Fibrin taken from the dead bodies of healthy individuals, presents
tolerably  compact and  tough, moderately adhesive  coagulations of a
yellowish white.  These are separable into membranous layers, and their
torn surface  exhibits a delicately villous character.  Viewed under the
microscope,  they display a transparent basement,  capable  of membra-
nous expansion, or else stratified.   Upon this is  a dense  felt, freely 
COAGULATED  FIBRIN.
83
erect at the edges of the preparation, and consisting  of very minute,
very elastic, ramified fibres, visible in black outline, and rapidly soluble
in acetic acid.   Hard  by on the preparation, are seen numerous round
polished nuclei, which, when treated with acetic acid, are brought more
distinctly into relief.   Beside these lie scattered minutely granular, dull,
round, and elliptic nuclei, and  similar cells, the  size of pus-cells, color-
less blood-globules, lymph-globules (fibrin-globules, according to Mandel),
the same form-elements  which, in  exudates, are termed plastic cor-
puscles (Bennett) exudation cells   (Henle).   (See  also  Pappenheim,
Addison, and others.)
   The soft, jelly-like  coagula  of so-called   spurious  fibrin,  found to
accompany the above-mentioned compact coagula, and  in  certain cases
to constitute the whole of the impoverished fund of fibrin, show the same
composition.   They constitute, we think, a transition form from albumen
to fibrin, of great moment in relation to the normal process of nutrition.
   2. Fibrin the coagula of which, though of the ordinary appearance,
possess the property of adhesiveness in a more marked degree, and fre-
quently inclose not inconsiderable quantities of serum.   Examined with
the microscope, they present a  laminated basement, and  one splitting
into fibres, flattened or roundish, rough,  and firm, or resembling organic
muscular fibres; or else a membranous basement invested with delicate
wavy fibres, upon  which, amongst elementary granules, are seen  nume-
rous round, black-edged nuclei, sometimes rod-shaped, or drawn  out into
fibres,  and again, more especially in the moisture  poured out, dull, round,
and oval nuclei, and analogous cells.  This  fibrin  enters—along with
rudiments of the preceding  one—into frequent  combinations with those
about to follow.
   This and the preceding fibroid together furnish the basis of numerous
areolar or fibrinous new growths, whether simple or combined with other
blastemata, both within and without the vascular system;  textural de-
velopment having set  in  with  the process of coagulation itself.  The
exudation of the last specified form  of fibrin is  especially wont  to ac-
company morbid processes; for example, inflammation, and frequently
in considerable  abundance.  It  might be designated, for distinction's
sake, as plastic or organizable fibrin.
   3. Fibrin, the coagula of which are marked by opacity, and by a dull-
white  aspect shaded with yellowish,  or with  yellowish-green.   They
frequently include, besides blood-serum, blood-corpuscles in considerable
amount, thus giving proof both of augmented  coagulability, and greater
rapidity of coagulation.  They are opaque, and  of various shades of red.
Microscopically examined, the coagulum  presents a stratiform  or fibro-
laminated basement, or else a  faintly striated  membrane, both being,
however, opaque, owing to  delicate granulation  (Punktmasse).   Upon
this, as also in the serum, are seen a vast number of nucleus-like forma-
tions, of developed, dull granulated nuclei, and of similar  more or less
developed cells.   Frequently the coagulum appears to consist altogether
of the two  last-mentioned elements, with a  proportion of granulated
structure.  The nucleus-formations all manifest  the usual neutral rela-
tions  towards acetic acid.   This fibrin  possesses little adhesive pro-
perty. 
84
COAGULATED  FIBRIN.
   4. Fibrin presenting in a higher degree the morbid characters  mani-
 fested in the preceding variety. The coagula are extremely opaque, and,
 where  they inclose no blood-corpuscles,  of a more  marked greenish-
 yellow tinge.   Frequently, however, they do inclose  vast  quantities of
 blood-corpuscles, and are of a reddish-gray or a reddish-brown, denoting
 rapid coagulation.  Upon a closer examination, they are found to consist
 of a compact, delicately granulated mass of nucleus  and cell-formations
 (assimilating in various degrees to the pus-cell and pus-nucleus), all held
 together by a tough amorphous intercellular substance.  There is neither
 fibrous tissue nor any fibrillation.  These coagula possess still less of a
 cementing property.
   These two latter forms we would designate as croupous fibrin.  Here
 the fibrin borders upon that in pyaemia, and has the croupous character.
 The cells and nuclei included in the coagulum are genuine pus-nuclei and
 pus-cells.   Other morbid conditions of fibrin—for example, the milky
 white opaque fibrin—are  of little moment as regards the present subject.
 They will be considered under the head of Crases.
   These forms of fibrin possess, from the very first, an indwelling prone-
 ness to textural formation, and a disposition to molecular disintegration
 —nay, they have already  entered upon both  the one and the  other
 transformation.   The fibrin 1 and 2, are organizable; the fibrin 3 and
 4  suffer disintegration; portions of the fibrin 1 and 2 that mingle with
 it being alone susceptible of textural transformation, as is so frequently
 witnessed, extraneously to the vascular  system, in exudations of a kin-
 dred stamp.  Fibrin 4 presents no definite coagulum at all.
   These forms of fibrin correspond in some measure with Mulder's gra-
 dations of the oxidation of protein.  Here,  however,  chemical  analysis
 has assuredly not kept pace with anatomical facts.
   Coagula assuming as it were the form  of intercellular substance, are
 liable  to  both  kinds of  metamorphosis.   The differently apportioned
 nucleus and cell-formations here  play a subordinate part, their  import-
 ance  varying, as has been stated,  from the nucleus employed in the
 fabric  of textures, to the  true pus-nucleus  and pus-cell.   Hence  they
 are the manifestation either  of a quantitative endogenous development
 of textural rudiments, or else of a qualitative affection of the plasma.
   1. The structural transformation comprised in the process of coagula-
 tion, consists in the afore-mentioned diverse fibre-and membrane-forma-
 tion.   The nuclei themselves, sometimes  appear  elongated into rod- or
 perhaps spindle-shaped  fibre-stems.  In  the cells  the caudate form of
 development is seldom observable.
   2. The second metamorphosis is  disintegration.   It is  foreshadowed
 in the granular mass that enters into the coagulation.   After probably
 a brief interval,  the entire coagulum resolves itself into a pulpy, cream-
like, whitish, or yellowish-white, or, if containing blood-corpuscles, into a
 proportionally faint reddish-gray, reddish-brown,  or chocolate-colored
 liquor, pregnant with granulated substance along with the  nucleus and
 cell-formations originally admitted into the  coagulation, and becoming,
 where the latter are numerous, relatively analogous to, and where  they
 assume the  character  of pus-nuclei  and pus-cells, identical  with, pus.
 This breaking down may, under certain external conditions, unfavorable 
COAGULATED  FIBRIN.                   85
to textural formation, or  owing to some indwelling  peculiarity, affect
fibrin generally.   In croupous fibrin it is of  unfailing occurrence.  The
results of Gulliver's experiments concerning the liquefaction of fibrinous
coagula, under the sustained influence of the animal degree of heat, out
of the  animal body, are  not applicable to the process as occurring
within the living body, where  certain kinds of fibrin of necessity become
converted into textures, whilst others as  invariably liquefy.
   This process is witnessed with especial frequency in  the coagula occur-
ring within the heart, and which  Laennec designated as "vegetations
globuleuses,"  as also in the coagula occurring within  bloodvessels, both
great and small.
   Liquefied fibrin  is capable of  undergoing inspissation and  cretaceous
conversion.
   Other transformations of fibrin are:
   3. The  abiding  of the  organizable fibrin  at  the primitive stage of
formation, and its  eventual extinction.   Here the coagulum is, with loss
of its moisture,  reduced  to a  compact,  unyielding,  semi-translucent, or
opaque and horny substance.  It is capable of eventually ossifying.
   4. Fatty conversion, in the shape of a reduction to fat-molecules of
various circumference, a metamorphosis  which  coagulate fibrin shares
with liquid and coagulate albumen.
   5. Within the vascular apparatus solidified albumen, of whatever form,
may again become incorporated  with the  circulating fluid.  Where this
liquefaction of the coagulum is not  the consequence of inherent disposi-
tion, it is  wrought by gradual  solution in the plasma, becoming,  so to
say, corroded, layer for layer, by the liquor  sanguinis.  Examples offer
in the progressive  resolution of solidified vegetations upon  the  heart's
valves, or of the thrombus in arteries.  It corresponds to the  resorption
of the consolidated fibrin of exudation and of extravasation.
   We have hitherto expressly restricted ourselves to an inquiry con-
cerning the consolidation and the  metamorphoses of fibrin within the
vascular apparatus, as exemplified  in the diverse spontaneous coagula-
tions which occur in the heart,  not rarely  during life; and again in coagu-
lations within the larger vessels  (more especially the veins), and also in
the capillaries.
   The relations of the fibrin of exudation are precisely the same.
   The organizable nature of the fibrin of exudation might be  confidently
assumed a priori;  it is, however, as  shown under the head  of hemor-
rhage, directly demonstrable by  facts.
   Contrasting the  frequency with which  solid blastemata constitute the
basis of pathological new growths, with their rareness in the physiologi-
cal condition; reflecting, at the same time, upon the predominance  of
cell-development in physiological structures; and lastly, upon the absence
of fibrin in the embryo, we feel somewhat disposed to  concur  with  Zim-
mermann, in regarding fibrin as  a genuine excretive formation;  a sub-
stance carried by oxidation to  the verge of disintegration,—albumen
worn out by oxidation, and  associated with albumen for the purposes of
nutrition, only in the shape of pseudo-fibrin. 
86
METAMORPHOSIS  OF  BLASTEMA.
                   METAMORPHOSIS  OF BLASTEMA.

   1.  Textural development.—Organization.
   Solidified  Blastemata, at  their very  development, either constitute
various pure  and unmingled new growths, or enter in the shape of inter-
cellular substance, basement- and bond-mass, as the stroma into the com-
position of complex heterologous structures.   Their development is, for
the most part, foreshadowed  in the types cast in the process of coagula-
tion,  and which  were partly discussed in the  foregoing chapter.
   The  principal abiding form-element  that  enters into the composition
of new growths is the anastomosing, delicate fibrous network of consoli-
dated fibrin.  This,  together  with a hyaline  intercellular substance,
speckled throughout with shining nuclei, we have  seen in old inflamma-
tory indurations in the  brain, as also composing an extensive fibrous
cancer in the stomach.
   Solid blastema either appears originally as  a  compact  mass, or else
takes up a  considerable  amount of moisture, and establishes  a sort of
skeleton-work with variously shaped gaps, offering  a specific type of much
interest.  From a central mass, namely, arises a trelliswork, the rods of
which are  sometimes isolated, sometimes  anastomose with each other,
constituting a network with largish, and for the most part, oval  meshes.
This type characterizes  in particular the  opaque accumulations found
upon  the internal coat of arteries, as also certain fibrous tumors,  espe-
cially when seated upon the  dura mater.  Or, again, solid blastema as-
sumes the form of a membrane, either superficially spread out, or folded
and rolled up in a tubular form,—a cylindrical fibre.
   The blastema is here amorphous, laminated; or it presents upon lace-
ration, a striated, fibrous aspect.  It  may assume, owing to the presence
of elementary molecules, various degrees of opacity, or a granulated look;
or it  may display crystalline clearness.  Lastly, it may or  may not in-
clude nuclei and cells, in various proportions.
   Solid blastema of each of the specified forms is  worked out into fibres
by splitting:
   1.  Either directly into areolar fibre and fibril, or else
   2.  Into  flat,  riband-like,  rough-surfaced, jagged,  or into  roundish,
oval,  mostly  felt-like fibres, of from T£o to 55th of a millimetre in their
broad diameter.
   3.  Into fibres perfectly identical with those of the organic muscles.
   By renewed splitting, for the most part commencing at their ends, the
two latter kinds may give rise indirectly to areolar fibrillation.
   Where there  are nuclei present,  engaged  in  the  development  into
oblong nuclei, the splitting takes place in the direction of their longitu-
dinal axis.
   The aforesaid cylindrical fibres represent little  tubular bodies of from
TJxjth to y'oth of a millimetre in diameter,  which end either in bulb-like
dilatations, or in sharp points, frequently inosculate, and constitute a wide-
meshed villous  network.  Their parietes are formed by a transparent,
structureless, often wavy membrane, in a single or double fold.  Their
contents are elementary granules,—in hemorrhagic blastema, pigment-
granules additionally,—nucleus formations,  cells, together with an ampho- 
METAMORPHOSIS  OF  BLASTEMA.
87
rous blastema in varying quantity.  Cylindrical  fibre at its parietes be-
comes areolar fibril, or perhaps this fibrillation is first developed  in the
blastema  within the canal, as a delicately fibrous  wave-curled axis-
cylinder.   Such fibres are commonly coincident with the primitive forms
of blastema, more especially with the trelliswork described.   We have
frequently examined  them, and we regard them as analogous with the
cylindrical formations occurring in fluid blastemata (Engels germ-tubes.)
   Other kinds of fibre  arise directly out of splitting, but more slowly, it
would appear, and only after  the blastema has entered upon essential
chemical changes (as partial, glutinous, or horny conversion).  They are
characterized  by their neutral relation to acetic acid, or at least by their
stubborn resistance to its influence.  Through progressive transitions they
ultimately attain to uniformity with elastic and nucleus-fibre with which
they further accord in blackness of outline, in solidity, and in  elasticity.
Of this nature are
   1.  A transparent fibrillation for the most part solid, the fibre varying
in diameter from that of the areolar fibril  to one of undefinable minute-
ness.
   2.  A fibrillation in black outline, vibrating in  lengthy deviations.
   3.  A twig-like fibrillation arising out of a short stem, with black con-
tours.
   4.  A fibre-felt, resembling the intercellular  substance of reticulated
cartilage.
   The appearance in the blastema of roundish gaps, created by resorp-
tion,  is likewise deserving  of  notice.   In  this manner solid  masses of
blastema acquire a porous, honeycombed aspect, whilst membranous blas-
temata become  pierced or  loopholed  tunics.  This  does not, however,
prevent the blastema either from remaining amorphous or from  under-
going fibrillation.  Amongst the  elementary granules, nuclei,  and  cells
which occur in various  number in solid blastema, it is more  especially
the two former, and  most frequently  the  nuclei, that undergo  further
elaboration.
   1.  Even in  recent fibrinous coagula, within the vascular  system, rod-
like nucleus formations are discoverable.   They  enter into the composi-
tion of many delicately  fibred textures.
   2.  The nucleus is developed through the oblong form to the caudated
nucleus, and  from thence  directly into nucleus-fibre.  Upon  basement
membranes, we  often meet  with  serpentine, creeper-like nucleus-fibre
stems.  The  caudated  nuclei  often constitute, when  held  together by
an amphorous intercellular mass,—in rarer instances independently,—
the fibrous element of not a few heterologous growths.  More frequently,
however, they enter  singly into the composition of fibrous textures  of
other kinds.
   3.  Contiguous nuclei, in progess of fibrous development, conjoin and
merge in the varicose nucleus-fibre, which by degrees acquires uniformity,
and in rare instances forms the main component of fibrous new growths.
  4.  The nuclei form the basis of the true elastic splitting fibre.
  Elementary granules forming  in collateral array, become  confluent,
and establish  in various directions, more or less delicate,  dark-looking,
longitudinal, or  reticulated fibres, which  resist the influence  of acetic
acid.   They are most conspicuous upon basement membranes. 
88
METAMORPHOSIS  OF  BLASTEMA.
    In solid blastemata the elaboration of cells into fibre occurs, for  the
 most part, slowly and in the ordinary routine.   The majority of the cells,
 however, remain undeveloped, and  become reabsorbed.   Still  the  deve-
 lopment of primary cells into parent-cells, however rare, does occasionally
 happen.
    Fluid blastemata, in their development to  textures, obey the  laws of
 the cell theory (Schwann's).   The perfect nucleated cell, however, origi-
 nates in two different ways :
    (a.) The union of several elementary granules gives rise to the nucleus,
 and around this to the cell, with the nucleus impinging upon the wall,—
 the ordinary mode.   Or else—
    (b.)  The cell originates first,—its primitive limpid contents giving rise
 to an endogenous nucleo-genesis—for example, in the blood,—in exuda-
 tion—in colloid and medullary cancer.
    Generally speaking, the nuclei equal in size those proper to physiolo-
 gical  textures.   Larger nuclei, however, and  in  particular oblong, free
 nuclei y^th to BU^h 0I" a  millimetre in length, occur  likewise,—in me-
 dullary cancer, for instance. Inclosed within cells, their further develop-
 ment, so far as we know, commences only after the conversion of the cell
 into fibre.   They are round, oblong,  lustrous, black-edged, or dull and
 granulated.
   The cells present  every variety  of size, from  that  of  the exudation-
 and the pus-cell to that of the largest ganglion-cell, and upwards.  They
 are in shape spherical, oval, lengthened by branch-like processes, rhom-
 boidal, polyedrical.
   They mostly contain one,  often two, occasionally several (three,  four,
 or five), nuclei.
   The propagation of nuclei and cells occurs either immediately out of
 the fluid  intercellular substance, as blastema, or within a parent-cell.
 Endogenous nuclei and cells [brood-nuclei and cells; filial cells ; intra-
 utricular cell-formation] from within a primary cell, and distend  it into
 a structureless  vesicle, by the  eventual bursting  of which they become
 released.
   In rarer instances, we meet with secondary cell-formation around a
 primary cell,—an incasing of the primary cell.
   The primary  cell  is either permanent or adapted for ulterior develop-
 ment, namely—
   1.  The ordinary development of the cell into fibre.   This is brought
 about by the spontaneous  elongation of a cell to a wedge- or spindle-
 shaped, or a caudated cell; or  by the fusion of several cells, arrayed  in
 rows or columns, and engaged in the act of elongation to a varicose fibre,
 the protuberances of which are eventually reduced.  Fibre produced  in
either way may, by splitting  lengthwise, subsequently break up  into
fibrils.  In form, the fibre corresponds with that of areolar tissue, or  of
organic muscle.   The cell-nuclei immediately form into nucleus-fibre,
mto elastic fibre.  In this wise do fluid blastemata, under the progressive
 consumption  of the intercellular substance, give  rise to  fibrous  new
growths.
   2. The above transformation differs  from the working out of the pri-
 mary cell into the parent-cell, and to the production of pouch-like forma-
 tions with endogenous nucleus  and cell-development. 
METAMORPHOSIS  OF  BLASTEMA.
89
   (a.) The parent-cell is a cyst-like dilatation of the primary cell, and
its contents furnish the blastema for the  creation of  filial cells, in
either of the two modes before described.  When the latter have greatly
increased in number, the parent-cell frequently, but not invariably, bursts,
and is destroyed.   Not rarely, however, it becomes the groundwork for
very remarkable textures.  (See " Cyst.")
   (a.) The structureless parietes of the growing parent-cell  acquire  a
fibrous texture, and thus become fundamental to the type  of the alveolar
texture,  and to cyst formation.  (See " Cyst.")
   (/?.) The parent-cell  is singly, or it may be in fusion with others, de-
veloped into a gibbous, lobulated, hollow  body,  resembling a  glandular
acinus.
   The filial-cells enter occasionally, even within the parent-cell, into a
fibrous development.  Upon the dura mater,  tumors are often met  with
seemingly of glandular texture.   These  consist of conglomerations of
caudated cells, imbedded in a layer  composed of the same elements.
They are the products of a single parent-cell.
   (b.) In  fluid blastemata, utricular  or  pouch-like  formations occur,
similar to the  tubular fibres mentioned under the head of solid  blaste-
mata, and they inclose nuclei and  cells in various number.  Their walls
appear structureless ; although, on a closer inspection, one or two nuclei,
—occasionally several movable nuclei,—may  be detected upon them.
They occur in colloid,  in scirrhus, and in sarcoma, with a fluid inter-
cellular substance.  Their functional import is, in our opinion, identical
with that of the parent-cell with its  brood-elements.  They present the
greatest  analogy with the capillary vessel and its contents, the more so
that  they probably originate through  the fusion  of nucleated or  non-
nucleated  cells, arrayed in  columnar juxtaposition.   Their diameter
ranges from the y^h to the y^th  of a millimetre, and upwards.
   We have now examined the essential elementary forms arising out of
both solid  and fluid blastemata.   Their  secondary arrangement into a
texture offers equal diversity.  Nuclei, cells, nay, elementary granules,
display infinite variety in their arrangement, as do, in like manner,
caudated nuclei and cells, and the different descriptions of fibres, in their
course and in their co-ordination with other concurrent  elements.  These
relations  will  have to  be pointed  out in the  special analysis of new
growths, to certain of which, peculiar arrangements naturally belong.
   Other changes suffered by blastemata, either  in their primitive state,
or after having attained to different stages of development, are:
   1.  Resolution into a molecular  point-mass.   Blastema breaks up, in
its primitive state, owing either to positive intrinsic relations, or to the
absence of compulsory extrinsic conditions for its evolution.   Or, again,
it breaks up, after  having  already entered  upon a course  of develop-
ment, owing to the  cessation of the external  conditions necessary to its
maintenance and further elaboration.
   In the state of disintegration, it may undergo complete or  partial re-
sorption, with or without entailing constitutional mischief.   This process
is often attended with cretaceous deposition,  often with fatty conversion
of the protein-substances.
   2.  The  blastemata  stop   short  at different stages, retrograde,  and 
90
METAMORPHOSIS  OF  BLASTEMA.
perish.   This may happen at any epoch of their development, from the
primitive state  upwards.   The causes may be either inherent in, or
extrinsical to, the blastema.  In some instances  it  is a  natural death,
certain elements, epidermis-cells, for instance, dying  off, after having at-
tained their highest development.  This of course applies more especially
to solid blastemata.   In their primitive condition, they part with their
water, condense, and shrink into horn-like masses, and frequently ossify.
When more advanced  in  their  development,—for  example, to fibre—
such  elements  waste,  and  become  reduced  to  primitive  amorphous
blastema, which immediately shrivels, often disengaging calcareous salts,
that is, ossifying.  Within the cell there occurs incrustation, with amor-
phous granules  (a kind of granule-cells),  or in  stratiform  deposition.
Here the blastema has  become bereft of all faculty for further develop-
ment.
   3.  Conversion into fat,  occurs  both  in primitive  blastema and in
tissues, and it is frequently accompanied by the disengagement of salts
of  lime,—by cretefaction  and  ossification.   The  protein substances
undergo  a  transformation  into  free fat  in little molecules,  and into
cholesterine crystals.   To this  conversion  both solid  and liquid blaste-
mata are liable.  Where cells  exist, it occurs in the shape of granule-
cells.
   Vogel describes it as a peculiar  granule-cell  development, established
for the  resorption of an  inflammatory exudation.   " The exudation,"
says he,  "is  converted into nucleated  cells of 3^oth to y^th of  a milli-
metre in diameter.  These  cells progressively  enlarge,  until they have
attained the size of from ^th to g^th of a millimetre, and gradually fill,
at first with a few, afterwards with very numerous little  dark granules,
until the cell, originally transparent and colorless,  becomes thoroughly
opaque, assuming the brownish or blackish coloration of its contents, and
appearing as an aggregation of granules, which  cover and conceal the
cell-nucleus, and frequently even the cell's walls."
   The concomitant chemical changes consist in  the formation,  or at least
eduction, of a new (reckoning the cell's walls  and the cell-nucleus,—of
a third) substance within the granules, possessing the characters of fat,
and occasionally of salts of lime.   Vogel says, further on, " the matured
granule-cells are not susceptible of ulterior organic development.   After
they have attained  their  full size, and filled  with granule-cells,  their
further metamorphosis is a retrograde one.  The cell-nuclei  disappear,
becoming, like  the  cell's walls, reabsorbed, whilst the granules,  which
alone remain, and are  at first held together by a viscid  medium, finally
separate.  After  the complete  breaking  up of the  granule-cells, the
entire exudate  originally present  is converted into a semi-fluid, pulta-
ceous mass, which, with the aid of the microscope, is found to consist of,
as yet, unchanged granules out of the broken  granule-cells, natant in a
fluid,—the original serum of the exuded blood-plasma."
   With  reference to this process, which affects not alone inflammatory
products, but every kind of blastema, we have additionally to state :
   1. The process of granule-cell  development consists  not, we appre-
hend, in a development of fresh nucleated cells, and of  granules within
these.  The granules become developed rather within the already exist- 
HYPEREMIA.
91
ing cells, and also externally to them in the  intercellular substance.
There are seen distinct granules, which here and there collect in smaller
or greater number, and  occasionally assume an  investment, not distin-
guishable from the bond-mass by which they are held together.  Those
developed within the cells accumulate and distend the cell's walls, until
these give away and allow the granules to escape.   This process may be
directly witnessed, but it is further corroborated by the following circum-
stances :
   (a.) Where the blastema is devoid of pre-existent cells, it  does not
contain any nucleated  granule-cells either, but simply aggregates of
granules; for example, in  the  fatty  conversion of  certain  fibrinous
coagula, of primitive muscle-fibrils, and of fibrous new growths.
   (b.) The  exudation-cell, the pus-cell, the cancer-cell, as the case may
be, becomes the granule-cell, which  retains the form of the pre-existent
cell,—for example, the spherical, wedge-like, spindle-shaped, fibro-elon-
gated granule-cell.
   2.  This process is, in point of fact, the fatty conversion of the contents
of the cell.   It is the counterpart of the fatty conversion of protein sub-
stances in every variety of blastema, and even in tissues generally.   It
gives rise to emulsive  and  saponaceous  combinations, thus  proving
destructive to both blastemata  and new growths, which latter it would
indeed render fitted for  resorption, were this not often  hindered by the
simultaneous  disengagement of phosphate of  lime with  cholesterine
crystals.
   These changes run parallel with chemical ones, consisting in the de-
velopment of difierent kinds of gluten, in horny conversion, and the like.
   3.  Finally, blastemata (like physiological textures) become reabsorbed
at various stages of development, having become  adapted for the process
by a previous disintegration or fatty conversion,  although, in the case of
fluid  blastemata, without  any intermediate change.  Solid blastemata
may become gradually dissolved and fitted  for resorption by blood serum
percolating the textures, for example,  in  solid,  fibrinous, inflammatory
products.   Occasionally some of their nuclei are left behind, presenting
the only visible residue of  comparatively extensive blastema masses.
   Our next inquiry concerns the conditions  which favor  the throwing
out  of  pathological  blastemata in  particular localities.   These may
consist in an exudatory process, not differing  from that which presides
over the normal  act of nutrition, or else in processes which,  though akin
to physiological,  are, in strict parlance, pathological.   Such are hyper-
aemia, and inflammation in its numerous  modifications.   Again, blaste-
mata become consolidated  within  the vascular system  through  the
coagulation of fibrin, as metastases, or deposits.

                            HYPEREMIA.
   It is to be understood that we have to deal only with local hyperaemia
—congestion, so called.
   It consists in an excessive  amount of blood in the capillaries of an
organ;  that is, in an  injected condition of this latter, exceeding what
experience has shown to be its  average.   This is not possible without
dilatation of the  vessels, nor can we  admit the existence of congestion 
92
HYPEREMIA.
with coarctation  of the vessels, and a consequent accelerated  passage
of the blood through them, which some have designated as active con-
gestion.
   A simple comprehensive view of the development of hyperaemia is not
feasible, the conditions not being  always the  same.  It will, perhaps,
suffice to distinguish between active,passive, and mechanical hyperaemia.
We shall here, however, not consider these individually—more especially,
the two  former—further than  may be requisite for the establishment
of a principle.   Their closer investigation will be more appropriate under
the head of Inflammation.
   1. Active hyperemia is the result of external or  internal  stimuli
acting immediately upon an organ, or reflected to it from other organs,
—irritating the sensitive nerves, and thereby causing antagonistic palsy
of the  nervi vasorum or (according to  another theory), evoking an in-
creased afflux of blood, a preternatural affinity of the parenchyma for the
blood.
   To this category belong, for the  most part, those  hyperaemiae, depen-
dent upon external or internal causes", which precede inflammations; most
of those habitual, constitutional hyperaemia, rooted directly in the nerv-
ous system or in the  blood; again, those hyperaemiae occasioned by
augmented activity, by overwrought function, or concurrent with excited
conditions  of the organs.
   2. Passive Congestion  depends upon  direct palsy of  the nervi vaso-
rum, wherewith  is commonly associated  a depressed energy in the re-
mainder of the nervous system.  The palsy may originate in the centres,
or it may be peripheral.   It is often determined by dyscrasis, and espe-
cially by the higher degrees of decomposition of the blood.
   To this class must be referred those hyperaemiae, introductory to so-
called asthenic inflammations, in organs exhausted by excess of functional
activity,  enfeebled by hyperaemiae  and  inflammation, or paralyzed;  as
also in those hypostatic hyperaemiae of the lungs, of the abdominal and
pelvic organs, of the common integuments, which are developed under
diminished impulse from the heart,  in dependent parts of the body, dur-
ing the progress of various adynamiae and marasmi.
   3. Mechanical hyperaemiae, namely,—
   (a.)  Hyperaemiae arising from palpable mechanical impediments to the
return of the blood through the veins, or to the ultimate disgorging of
the venous trunks into the heart.  The extension  of the hyperaemiae
varies with the locality of the impediment.  It affects single organs and
sections  of organs;  for example,  a portion of intestine  strangulated,
invaginated through tension and compression of its bloodvessels.  Or it
may have  a more comprehensive range in impermeability of the liver,
of the lungs, in stenosis (coarctation) of the heart's valves.  The hyper-
aemiae occasioned by spontaneous coagulation within the capillaries, by
various elements  obstructive of these vessels,  as  pus-corpuscle, cancer-
cell, injected mercury globule,  are commonly referred to the same head.
   (b.)  Hyperaemiae ex vacuo, as they occur in atrophy of the brain within
the unyielding skull, or in the gravid uterus after rapid delivery, often
to the extent of producing hemorrhage; hyperaemiae due to the eccentri-
cal rarefying atrophy of organs. 
HEMORRHAGE.
93
  The hyperaemiae is either of a  more or less transitory or of an abid-
ing nature, of which  latter kind mechanical  hyperaemiae,  from heart
disease or from induration of the liver,  present the most  frequent  and
the most marked examples.
  The sequelae of hyperaemiae are multiplex, varying with the duration,
the repetition, the degree, of the congestion.  Much likewise depends
upon the character of the affected organ, the congestion being significant
in proportion to the  general importance of such organs, and to the  vul-
nerability of its texture.   Organs are prone to  congestion  proportion-
ately to their vascularity and to the degree of  their functional activity.
Under particular circumstances of life, of occupation, of civilization,  cer-
tain organs, such as the  brain and its  membranes, and the lungs,  are
hardly ever entirely  free from congestion.   Hyperaemiae affects morbid
growths equally with normal formations.
  Intense  congestion  suddenly  developed in  organs  essential to  life
(the brain or lungs) may prove fatal  directly,  as  so  termed vascular
apoplexy, or through the sudden  effusion of blood serum  into  the  tex-
tures—acute oedema.
   High degrees of congestion occasion laceration of capillaries and pa-
renchymatous hemorrhage (apoplexy with bloody extravasation) in  the
brain,  the lungs, and other organs.
   The same causes  lead, by an overloading of the bloodvessels, to abso-
lute palsy of the bloodvessels, to  stasis, inflammation, and gangrene.
   Moderate  but habitual or repeated congestion gradually engenders
oedema and the  dropsy of serous cavities—genuine  dropsy, increased
exudation  of  blood  plasma, preternatural nutrition of the textures—
hypertrophy, augmented secretion.
  In this relation, abiding mechanical hyperaemiae, from heart disease,
are worthy of especially notice, with their unfailing consequences, hyper-
trophy of the glandular abdominal viscera; preternatural  secretion of
the intestinal and bronchial mucous  membrane;  excessive,  saturated
secretion of bile.
  Hyperaemiae create and bequeath permanent dilatation and elongation
with coil-like or serpentine deflection—properly termed varicosity—of
the bloodvessels, as more  particularly exemplified in  the  less  resilient
veins.
  Hyperaemiae frequently  occasion and  obviously accompany the deve-
lopment  of various heterologous  growths.   Finally, in some  organs, a
proportion of blood-pigment, effused with  the plasma, constitutes  the
basis of rust-colored,  slate-gray, bluish-black coloration, as in the lungs or
on the intestinal mucous membrane.
  Organs attacked by a high degree of hyperaemia present different shades
of dark red, become swollen, loosened in texture, and consequently friable,
lacerable.  In organs  of  a porous spongy texture,  the swelling seems
due to  a bloated condition of the  tissue itself.

                            HEMORRHAGE.

  Hemorrhage consists in the extravasation of blood bodily, and in its
entirety, from the bloodvessels, consequent upon a breach of their  con- 
94
HEMORRHAGE.
tinuity.  Herein it differs from red effusions resulting from the transuda-
tion through the parietes of vessels of blood serum, which, owing to various
changes of admixture, has taken up blood pigment.   Hemorrhage occurs
either within textures, when it is with  reference to its attendant para-
lysis, somewhat inappropriately termed apoplexy; or else within natural
or preternatural cavities or canals; for example, in  serous sacs, in muco-
membranous cavities or canals, pus-reservoirs, &c.   The two kinds fre-
quently coexist.
   Heterologous growths are, in the same degree as normal formations,
subject to hemorrhage, those at least which are highly vascular ;  as, for
instance, adventitious membranes, carcinoma (in  a high degree), the inte-
rior of cysts, &c.
   Hemorrhage depends  upon  various causes, the  most common cause
being,  as before stated, a breach of continuity in the bloodvessels.
   Apart from  hemorrhages  produced by external  injury inflicted upon
bloodvessels, whether  alone  or in conjunction with other formations,
those resulting  from the following momenta, more especially capillary
(parenchymatous) hemorrhages, possess a high degree of interest.
   1. Hemorrhage the result of  intense hyperaemia, of whatever kind.
Thus,  active hyperaemia  has a  marked  tendency to create bronchial
hemorrhage, passive hyperaemia uterine hemorrhages, hyperaemia from
mechanical causes, in particular the bronchial and intestinal hemorrhages
that result  from heart disease, and the cerebral hemorrhages induced by
a vacuum within the skull.
   Finally, the excessive accumulation of blood determines rupture of the
capillaries.
   2. Another step  conducts us to hemorrhage  as occurring during the
progress of inflammation, namely, in the  stages of congestion  and  of
stasis.   In this combination we have hemorrhagic inflammation, and the
in many respects remarkable exudation designated hemorrhagic.   Here,
as in simple hyperaemia, the  hemorrhage is unfailing, and considerable
in proportion to the extent of the congestion and stasis, as also to the
delicate, lax, and vulnerable, nature  of the implicated texture. Any
one of these influences may predominate to a various extent.   There are
organs in which, owing to the nature  of the texture, inflammation never
takes place without hemorrhage—for instance, the brain, the lungs, many
heterologous formations, and  especially  exudates undergoing a change of
structure, and loose cancerous textures.   The hemorrhage is capillary.
   3. Hemorrhage from the laceration of  vessels, produced in atrophied
organs by the laxity and diminished resistance  of  surrounding textures
—apoplexy of the decrepit uterus.
   4. Hemorrhage from the spontaneous laceration  of organs diseased in
texture, pulpy and friable—laceration of the heart.
   5. Hemorrhage from laceration of vessels consequent upon impaired
texture of their  coats, with  or without dilatation  of their calibre.   It
affects the  smallest bloodvessels as readily as the main trunks, and more
especially  the  arteries.   Other coincident  causes—hyperaemia,  for ex-
ample—greatly favor its occurrence.
   6. Hemorrhage  consequent  upon  the  destruction of  bloodvessels
by ulceration,  or  by contact with a free acid, as in softening  of the
stomach. 
HEMORRHAGE.
95
  It is questionable  whether,  and in what way, dyscrasial states can
give rise to hemorrhage.  A relaxation of the coats of bloodvessels  suffi-
cient to admit of the passage through them  not only of plasma, but also
of blood-corpuscles, is by no means proved, and its assumption, to explain
the hemorrhage occurring in scurvy or typhus, needless.  The sponta-
neous hemorrhage arising in the progress of such maladies, is the result
either of local hyperaemia and inflammation, into which those general
diseases  have resolved  themselves, or  else of preternatural expansion
(increased volume) of the blood itself, and of the consequent rupture of
bloodvessels in the looser  textures, such as  the gums, the mucous mem-
branes, and the lungs.  Hence the occurrence of hemorrhage in several
organs simultaneously, and again the predominant invasion of a few par-
ticular organs.   That hemorrhage, having  once set in under such cir-
cumstances, is apt to become excessive,  is due, without any doubt, to the
slender coagulability of the dyscrasial blood.
  Hcemorrhophilis—habitual hemorrhage—depends, so  far as  we  at
present know, upon a preternaturally  delicate and vulnerable structure
of the  coats of the vessels, coupled with a thin, watery, condition of the
blood.
  Hemorrhage greatly varies in intensity.   Its  character  is  to be esti-
mated not merely by the quantity of blood thrown out either externally
or into internal cavities and canals, nor by  the  degree of anaemia  that
follows, but also, where the  parenchyma  of organs is its seat, by the
anatomical condition in which we find the diseased parenchyma.   In
slight hemorrhage, the texture appears here and there dotted or streaked
with extravasated blood,—Capillary apoplexy.  As the hemorrhage in-
creases, these dots or streaks become more crowded, the  parenchyma,
more turgid, until its  interstices and  cavities having at length become
uniformly surcharged with blood, it appears throughout red.  Or, where
the blood has become coagulated, the rough texture seems as if converted
into a blood placenta, whilst a diminished  coherence  of its molecules,
and numberless lesions of continuity have rendered it friable, easily torn
[mucous  membrane, lung].   Such is the condition  of the  denser, more
resisting  textures; in those of a more lax  nature, or  where the hemor-
rhage has been  sudden and violent, the texture  is completely swamped
and crushed into a red pulp of various shades, or else more or less lacera-
tion of texture has taken place, and the gap so  occasioned become the
recipient for the extravasated blood—apoplectic foyer.
  The extravasated blood varies in deportment according as it is circum-
stanced subsequently to its extravasation.   Certain influences cause it to
undergo rapid and unusual changes: for example,  in  the  stomach and
intestines, black coloration  and  liquefaction  of  its fibrin, through the
influence of gastric and  enteric  acid.
  Blood  poured out into cavities  and  canals, or into  textures,  is either
fluid or in various phases of coagulation.  Of these phases, coagulation
with central  or peripheral  encysting separation of fibrin is the most
important, owing to the increased impediment which it offers to the pro-
cess of absorption.
  The immediate effects of hemorrhage, besides  the anaemia consequent
upon great effusion, either out of the body,  or into its cavities, are lesion 
96
HEMORRHAGE.
of continuity in textures, in the shape  of the  swamping,  crushing, or
extensive laceration before referred to—impaired or destroyed function,
paralysis of the organ affected—cerebral, muscular hemorrhage.  A less
immediate effect is the inflammation of surrounding textures, occasioned
by  actual injury, and  by the  irritation of the extravasated fluid, as a
foreign body, with eventual organization  of the products effused, callous
condensation of the nether layer,  and  capsular  isolation of the  hemor-
rhagic clot.   Inflammation, resulting in purulent and ichorous products,
in parts broken up by hemorrhage, is of  rarer occurrence. ^
  Hemorrhage is both in itself, and in its results, of significance com-
mensurate with the importance of the organ affected.
  The cure  of hemorrhage is a process simple or complex  in a degree
corresponding to the amount of blood effused, to its character as coagu-
lable fluid, and to the extent of the injury  suffered by the parenchyma.
  Slight hemorrhage is readily cured through resorption of the  effused
fluid,  enabling the distended textures to  recover their  resiliency.  The
liberated red  pigment, however,  frequently resists  absorption, even in
slight  hemorrhage, remaining  strewn, for the most part  in  a state of
minute molecular  dispersion, over membranous formations, or  between
the elementary parts of a texture, as a brown or black  pigment.
  The remedial process is  difficult and  complicated proportionately to
the amount  of blood extravasated, to the resulting destruction  of texture,
and to the solidity of the coagulated fibrin as a central or  a  peripheral
secretion from the fluid thrown out.   It  is a process of slow  gradation,
involving the changes  produced not  only in the  effused blood with its
red pigment and its fibrin, but  also in  the surrounding  textures.  These
changes  occur simultaneously, and we  have frequent opportunities of
observing them in areolar tissue,  in muscle, and especially in the brain.
   The crushed and disorganized texture  within the walls of  the foyer,
together with the extravasate itself, undergoes liquefaction, at the same
time that hyperaemia and stasis become developed in the adjacent texture-
layer. The  medium is probably almost exclusively supplied  by the blood
serum of the extravasated fluid which  undergoes many changes in  com-
position  adapting it for the liquefaction  of the  different substances;
namely, the solidified fibrin  and  the remaining elements proper to the
effusion—blood-globules, nucleated and cell-formations, debris of tissues.
How  important a part the liberation of adipose, and of saline  substances
out of their primitive combinations herein plays, is sufficiently attested
by microscopic analysis.  The blood-pigment incurs a special change.
It is converted, partly within the blood-corpuscles, partly  extraneously
to them, into a brown, rusty yellow, or into a blackish-brown, or a black
pigment.   This is  shown as well in  the  form of  spherical  corpuscles,
which resemble blood-globules  and are frequently seen accumulated  in
compact congeries, as also in  the shape  of elementary granules (granu-
lated pigment), either  discrete or in  circular groups.  These are  com-
monly free, but now and then  inclosed within cells, or suspended from
little  prismatic crystals of ammonio-phosphate  of  magnesia.   Together
with them is found, at the part involved, fat  in a  free state, fat in the
form  of little  black-edged, discrete or  aggregate  molecules, of limpid
drops, of cholesterine  crystals.   Again,  there are found elementary 
HEMORRHAGE.
97
molecules down to the minutest pulverulent molecular mass, consisting
of minutely subdivided, suspended fibrin, albumen, and fat,  with calca-
reous salts.  Finally, we have  amorphous, membranaceous, stratiform
coagula, nuclei, and blood-disks  (the as yet integral elements of the effu-
sion), and amongst them all detritus of the involved texture.
   In this manner the greater portion of the hemorrhagic effusion would
have become fitted for resorption.  The process is, however, impeded at
this juncture, by the inflamed condition, and at a later  period by the
hardened character of surrounding textures.
   Hence the ulterior metamorphosis  of the  effused mass, namely, its
progressive thinning and clarifying into a mere pale buff, or, it may be,
colorless liquid.
   What, amongst other things, has become of  the pigment ?  Partially
it may  have perished amid the  unknown, final conversions of the fluid
above characterized.   To some extent, however, it is preliminarily taken
up into a formation which,—derived from the coagulable contents of the
effused fluid—invests the walls of the foyer.
   This colored, soft,  jelly-like,  loosely adherent  lining,  eventually be-
comes endowed with a minutely fibrillated structure, and even with blood-
vessels, and is at length converted into a  delicate, and, if the pigment
be destroyed, into a colorless membrane, resembling a serous tunic.
   Meanwhile,  the inflammatory process has engendered in the walls of
the foyer products which serve, in the  shape of a nucleated blastema (to
be afterwards developed into fibrin texture of various kinds, and, into
areolar tissue), to condense and harden the textures.   Thus, the original
hemorrhagic foyer is changed  into  a capsule or cyst, which, when it
occurs  in the cerebrum, is termed apoplectic cyst.
   This cyst is susceptible of diminution, and eventual closure, through
resorption of its contents,—of closure  to a cicatrix which often contains
a certain kernel consisting of the aforesaid residuary pigment.
   It must be confessed, however, that the complete closure of the cyst
is a work of time and difficulty.  This is intelligible from the slender
absorbent faculty  of the surrounding  textures in their  condensed and
hardened condition.   Occasionally, special obstacles stand in the way of
this process of reduction ;  for example—
   1. Great extent of the hemorrhagic  foyer, and of the resulting cyst.
   2. A vacuum, created either  through original  retraction, or through
 subsequent wasting of the texture involved, in muscles and especially in
the cerebrum.  In the brain, indeed, a later supplementary enlargement
 may take place in the apoplectic cyst, as an expletive  of the vacuum
 created within the skull by consecutive atrophy  of the cerebral organ;
 for the internal  capsular membrane  is,  by reason of its  vascularity,
 adapted alike for secretion and  for absorption.
    3. A very remarkable obstacle to the collapse and closure of the cyst
 consists in the secretion of fibrin in the shape  either of central bulky, or
 else of peripheral  isolating coagula,  for the most part tinged by no in-
 considerable proportion of embodied blood-corpuscles.   These coagula,
being originally very dense, and retaining their  solidity even when con-
verted  into a fibrous  texture, resist, when central, the liquefaction, when
peripheral and encysting, the resorption of their contents.
   VOL. i.                          7 
98
ANEMIA — INFLAMMATION.
  Certain  cases offer various exceptions  to  the processes hitherto de-
scribed.  Thus, some cysts having, in spite of the  peripheral encysting
coagula, parted with their blood-serum by early resorption, are found
replete  with  a dark-colored, inspissated,  dry blood-plug; or else with
fibrinous, stratiform, villous masses, developed out of the partially ab-
sorbed vehicle.
  The frequency of hemorrhage varies greatly in the different textures
of the organs.   A scale of frequency is indeed but of very limited use,
since hemorrhage is  the result of various disturbances,  and,  in most
instances, of the concurrence of  several.  Generally speaking, hemor-
rhages of the brain and of the bronchial  mucous membrane are distin-
guished by their frequency;  those of serous membranes are very rare, if
we except the cerebral arachnoid sac.
  It was signified at the outset, that the mere exudation of colored (red)
serum, devoid of blood-corpusles, is perfectly distinct from hemorrhage.
It is found as so called petechiae (ecchymoses) in all textures, and in
serous and mucous cavities as colored effusion.  It  is due  to decomposi-
tion  of the blood.

                              ANEMIA.

  The chapter on hyperaemia naturally leads to a passing consideration
of the opposite state, namely ancemia.  Just as we have before treated
only of local hyperaemia, we shall here, in like manner, limit ourselves
to the subject of local  anaemia.   It comprehends both oligaemia, or  an
insufficient measure of blood in relation  to what experience has shown
to be its just standard, and true anaemia of an organ.
  It is present under various conditions :
  1.  As the partial manifestation of general anaemia.
  2.  As the  consequence of hyperaemia of one or more other organs.
  3.  As the  result of coarctation and closure, or orificial  obstruction of
the vascular trunk supplying the diseased organ or part, pending the
establishment of a compensating collateral circulation.
  4.  As the  effect of external or internal pressure upon an organ, and
its consequent inadequate injection ; anaemia of the lungs  from pleuritic
effusion ;  anaemia of textures the interstices of which are filled up with
morbid  products, as in  hepatization of  the lungs, in fatty infiltration of
the liver.
  5.  As a consequence of decay of the vascular apparatus of an organ
affected with atrophy, whether primary  or  secondary, more especially
atrophy with condensation (concentrical wasting).
  The effects of anaemia are pallor, collapse, and shrivelling of the tex-
tures, weakening and eventual extinction  of their function.
  Anaemia is momentous proportionately  to the vital importance of the
diseased organ, and to its exigencies with  respect to the supply of blood.
Thus, anaemia  of the brain,  of the lungs, of muscle, is of the highest
import.

                     INFLAMMATION, PHLOGOSIS.

  This pathological process is of paramount interest, not only on account
of its great frequency, and of the great  variety of external causes by 
INFLAMMATION.
99
which it is called forth, but also as being that in which most, and in  a
certain  sense  all,  general diseases become localized.  It is  a process
which leads inc6ntinently to the most various and most extensive new
growths, and associates itself, equally often, to other anomalous forma-
tive efforts.   In fine, it is a process which, on the one hand productive,
on the  other  hand  frequently proves destructive of both  normal and
anomalous formations.
  The inflammatory process is  capable  of being experimentally called
forth and observed, in all its phases,  in  transparent  textures.  Thus
studied, it has furnished the groundwork for the most varied interpreta-
tions, but, at the same time, for researches respecting other exudatory
processes.  Nor have  these experiments failed in a certain measure to
elucidate the connection that prevails between blastema and the endo-
genous formative processes carried on in the blood itself.
  We seek not to deprive this process of its time-honored name, inflam-
mation, because it  has become naturalized in  science beyond all others.
It is applicable enough, if in using  it we  simply dismiss the  theories
which first led to its adoption.   It comprehends the entire process, and
the efforts made to designate the latter differently have utterly failed.
Andral's hyperaemia,  and Eisenmann's  stasis have  not advanced  the
subject  by a single step.
  It is impossible  to  define inflammation  suitably, owing, on the one
side, to our imperfect  knowledge of its proximate causes;  and, on the
other, to the complex nature  of its consecutive phenomena.  These
latter, variously  modified  in  type, point  to  processes equally  varied,
whilst they at the  same time furnish the most  striking analogies with
other processes which issue in exudation  (production of blastema).
  Let us now proceed to a descriptive examination of the phenomena
which constitute so many  stages of the process, a due regard being had
to the results of experiment, that is, to the observation of the inflamma-
tory process as artificially called forth in animals.  And in this descrip-
tion, together with  the analytical  remarks  annexed to it, we will  take
for our  basis the so-called pure, legitimate, inflammation, which yields
essentially a coagulable,  fibrinous,  plastic product,  as  developed  in
sound organisms without  the  co-operation of a pre-existent dyscrasis,
and simply as a consequence of moderate local stimulation; such being
the most marked of any in its manifestations and stages.
  The phenomena  of  the inflammatory process present the  following
sequence.
  1. The moderate influence  of mechanical or  chemical stimuli is fol-
lowed by contraction of the capillaries, and  simultaneous quickening
of the bloodstream through them.  This phenomenon may be wanting
as an effect of most causes of  inflammation in the human species; and
even in experiments upon animals it is either transitory or entirely absent
if the stimuli applied be potent.
  Contraction of the vessels is succeeded sooner or later by—
  2. Bilatation of the  capillaries, if this be  not, indeed, the very first
cognizable phenomenon.   Unlike  contraction, it is  invariably present,
readily seen both in the living animal and in  the dead subject, as is, in
like manner, the simultaneous loading of the vessels with  an increase of 
100
INFLAMMATION.
blood.  It determines capillary injection, and therefore  the redness of
injection proper to inflamed textures.
   This dilatation of the vessels is attended by a retarding of the blood-
stream, which sooner or later, although not always visibly, merges in an
oscillating movement of the  blood  in the  capillaries.   The contained
blood-columns move forward and backward by turns, the onward move-
ment, however, predominating.   The  blood-corpuscles  begin to adhere
to one another, like rolls of coins, the outer linear layer  of  plasma (the
lymph space) within the vessel still remaining unchanged. ^
   This twofold proceeding establishes  the stage of congestion.
   3. Hereupon  ensues, sometimes so rapidly as  to prevent  the retard-
ment of the  blood-stream  and its oscillation from being noticed, stag-
nation of the blood-stream,—stasis.    The bloodvessels are completely
filled up  with  blood-corpuscles, so that the transparent,  so  termed,
lymph space, near the circumference of the vessel and before occupied
by plasma, has vanished.   Meanwhile the blood-corpuscles have  as-
sumed greater  intensity of  color, have become flattened,  contracted,
and firmly glued to each other, and to the vessel's walls, so as to form a
homogeneous red mass, with irregular translucent intervals.
   The nuclei and nucleated cells (so-called lymph-globules and  colorless
blood-corpuscles) have increased  in  number to an extraordinary extent,
often adhering  together in  groups  connected by delicate  transparent
coagula, and forming  either  thus, or  singly, the aforesaid translucent
intervals.   The  blood has assumed a dark  tile-colored  aspect, verging
upon cherry-red.
   In the  preceding  stage (see  hyperaemia),  as well as in this,  two
notable phenomena are witnessed, namely:
   (a.)  Laceration  of  bloodvessels, and extravasation  into the textures,
or into the  free  spaces,—lung-cells;  muco-membranous cavities  and
canals; serous sacs.   The hemorrhage is  frequent and considerable,
proportionately to  the degree of  congestion and stasis, and also to the
delicacy and the textural  looseness of the diseased part.   For the most
part it takes the form of capillary apoplexy, and only in very delicate
normal and anomalous textures, as, for example, the  brain  or encepha-
loid cancer, the form of the isolated clot.
   (b.)  Transudation  of blood-serum through  the thinned  bloodvessel
walls into the parenchyma, and from membranous expansions  into the
cavities and canals of which they form the lining.   This  implies, in the
parenchymata, ^ pervading  moisture,—in  expansive  structures,  diffuse
exudation or circumscribed accumulations beneath  the epidermis,—for
example, in burns, in vesication  artificially  called forth, in  erysipelas,
and the  like.  The exuded serum  resembles essentially blood-serum,
only that it is, for the  most part, less rich  in albumen.   This pheno-
menon often merges at once in the  exudatory process next  succeeding,
the two acts being simultaneous.
   4.  The step to which stasis  ultimately leads is genuine effusion, that
is, the  exudation  of blood-plasma,  a fluid holding in solution fibrin,
albumen,  and salts.   It is  thrown out into parenchymata, filling up
their interstices to a various extent, either  as a fluid, or as a more or
less solidified product.   Or, again, it  is partially, or, it may be wholly 
INFLAMMATION.
101
expended upon  the  free surfaces of natural  cavities  and canals, or of
such as  have arisen out of the  previous  transudation  of  serum,  for
example, in vesication of the epidermis, or in antecedent suppuration of
textures,—in abscess cavities.
  With  exudation, the inflammatory process is to  be looked upon as
closed.   It  is immediately  followed by an  endosmotic current of the
serous portion of the  effusion,  causing the blood-corpuscles to float in a
thinner  medium, to  exchange  their now  flattened for a more spherical
shape, to become separated, to  part with a portion of their pigment,  and
finally, by dint  of a returning resilience in the bloodvessels, to  move,
conjointly with the  aforesaid form-elements, onward again in the circu-
lating stream.
  We have  now furnished  the  reader with a substantial description of
the several acts which make up the process of inflammation.   We shall
further endeavor to  show how these may  be reconciled with the present
standard of pathological science.
  1. The first experimental phenomenon adverted to, namely, contrac-
tion of the capillaries, with acceleration  of the blood-stream, has been
stated to be inconstant, and  indeed absent  altogether, when potent
stimuli  have been used in the first instance.  Where it does occur, it is
to be regarded as a  vital phenomenon.   The contraction of the blood-
vessels  is moreover independent  of any simultaneous collapse of  the
parenchyma, like that produced, for example, by the action of cold.
  2.  The dilatation of bloodvessels  and  the retardment  of the blood-
stream are,  on the other hand,  constant and essential.   The very fact of
their being so  commonly  the  primitive  phenomena,  or  at any rate of
their succeeding very rapidly to  a previous  contraction, refutes  the
notion of their  consisting  in  a secondary  relaxation, resulting from
exhaustion.   With  these, and  with  the subsequent  stasis, the  theories
of inflammation hitherto advanced are mainly concerned.
  Henle reduces these  to  an  attraction-theory, and  to  a neuropatho-
logical theory.
  (a.)  The attraction-theory refers the essential phenomena of inflam-
mation to an augmented affinity between the parenchyma and the blood,
and especially to an anormal attraction of the  blood,  and of the blood-
corpuscles in particular, by the affected  parenchyma.  It assumes  the
retardation of the blood-stream, and the crowding together of the blood-
disks to be the primary—the dilatation of the  capillaries a  secondary
phenomenon.  It explains even the  stasis as a continued increment of
that attraction.
  The augmented attraction is effected through the intervention of the
nerves, and either by direct influence upon the peripheral  nerves,  or
else by reflection from the centres of the nervous system.
  The attraction-theory carries the  problem of congestion and stasis a
step farther, without  solving it.   Together with its common attribute,
namely,  an  increased  afflux of blood to  the  diseased  part,  as due to a
dilatation, and to a more frequent contraction of the  afferent artery, it
has been met by many valid  objections.  It is only the stasis and in-
flammation  engendered by a pre-existent dyscrasis that can, provided
the  attraction be not  limited to the  blood-corpuscles,  but embrace  the 
102
INFLAMMATION.
diseased plasma, warrant the conclusion of a  preternaturally strong
affinity between blood and parenchyma.  There would be some analogy
between such a localization of general  disease, and the indwelling rela-
tion of secreting parenchymata to certain  normal or anomalous ingre-
dients of the blood.   But these inflammations,  like the rest, are aptly
expounded in the neuropathological theory.
   The  neuropathological theory, on the contrary, assigns to the nerves
an  important part, and  ascribes  the accumulation of  the  blood to the
dilatation of the bloodvessels, this being set down as the primary—that
as the consecutive phenomenon.
   The  dilatation of the vessels is the  consequence of paralysis of the
nerves.  Respecting the  cause  and the conditions of  this paralysis,
there exist two different opinions.
   According to Henle,  an antagonistic relation prevails  between the
states of irritation  of the sensitive nerves, and of the nerves of the
bloodvessels: a high  degree  of inflammatory irritation in a sensitive
nerve  producing a  state  of depression—in a  word,  paralysis  of the
implicated bloodvessel nerves.
   According to Stilling, the sensitive and the bloodvessel  nerves bear,
on  the contrary,  a direct sympathetic  relation to  each other.   He
assumes a continual reflex action to be kept up by the  sensitive, upon
the  bloodvessel nerves, whereby the  tone  of  the latter  is sustained.
With  paralysis of the  former,  the  tone of the  latter is destroyed;
whereas by excitation of the former their reflective power is augmented,
and the tone of the latter thereby raised.   In accordance with this
reciprocity, two different kinds  of inflammation are made out.
   Griesinger was led to the adoption of a similar view, imagining pain
to result from a qualitative disturbance  of the texture of the nerve.
   Against this  hypothesis it  is to be objected  that a continued reflex
action of the nerves of  sensation upon those of the bloodvessels as a
necessary condition for the undisturbed function of those vessels is not
proved; and that the assumption of two  different characters of inflam-
mation, involves both  a contraditio in  adjecto, and  a  disregard of the
results of observation.   An inflammation with  augmented tone of the
bloodvessels  cannot exist, and this  admitted,  inflammation with and
through paralysis (diminished tone),  must  invariably ensue from  in-
fluences paralyzing to the sensitive nerves.  This is, however, opposed
to daily experience.
   Our own opinions accord with  those of Henle, whose theory we shall
therefore adopt as the groundwork of any future remarks on this subject.
   Even here the  causal momentum influences  the peripheral  nerves,
producing  either at the spot itself, or through  the  intervention of the
nervous centres, in  other  sympathetically  allied structures, excitation
and depression.  Or again, the influence affects the nerves within the
centres, the impression being conveyed from thence to the corresponding
peripheral  organs.
   The  stasis is not accounted for in the  neuropathological theory.   It
is, indeed,—
   3.  Not  intelligible  upon the ground of  paralysis  and  dilatation  of
the bloodvessels, even though [as we must admit a certain  off-flowing to 
INFLAMMATION.
103
take place to the veins] we may not regard the stasis as an absolute one.
For our own part, we  hold  stasis to  be dependent  upon the  following
momenta:
  (a.)  The cohering, crowding, and impaction of the blood-disks within
the capillaries, the blood-plasma being partly withdrawn into the veins.
  (b.)  The thickening  of the plasma, and its  saturation with fibrin and
albumen, owing to the transuding of  blood-serum through the distended
and thinned bloodvessel walls.
  (c.)  The accumulation of the colorless globules—that is, nucleus and
cell-formations—along with  the blood-corpuscles, their conglutination,
and  the  delicate transparent fibrinous  coagula collaterally developed.
This is, perhaps, the most important stage in the inflammatory process,
as at once illustrating the  stasis itself, and embracing the  plastic pro-
cesses  in which the blood engages when arrived at this point.  A line
of distinction is thus drawn between the inflammatory process, and a
simple process of exudation.   The form-elements  adverted to are not
merely washed together within the range of the  stasis ; they are new
creations  out of the blood so arrested, which at the same time undergoes
other remarkable  changes.   Thus  it is of a dark red, with a tile-colored
shade, contains red flocculent particles of cruor, visible to the naked eye,
teems  with the aforesaid elementary bodies, and with coagula, most of
which  latter  have incorporated a number of the former, as well  as of
dark-colored flattened blood-corpuscles.  The accumulation as well as
the general importance of those  (new)  elements, for the inflammatory
process, and especially the stasis, have been recognized by Addison and
others.
  The momentous question, as to the  cause of the said formative process
of blood in the condition of stasis, will be answered,  so far as it is possi-
ble, in the sequel.
  4. Exudation.—The thinning and permeability of the walls of blood-
vessels, produced by their distension, must be regarded as the basis of
this phenomenon, even in the instance of a condensed plasma; perhaps,
additionally, the effort at equalization betwixt the latter and any thinner
blood-serum before exuded.
  A question of peculiar interest here suggests itself, namely : wherefore
in the  inflammation of membranous expansions does exudation always
take place upon  their surface,  and into  the  cavities which  they invest,
whilst  the effusion beneath is limited to the infiltration of the implicated
parenchyma, or of the subjacent areolar tissue—with, for the most part,
an inconsiderable  amount of plastic  serum ?   This  applies not only to
mucous and serous membranes, but even to other more delicate hollow
bodies—for example, follicles.  The problem, like that of Johannes Miil-
ler, as  to natural secretions affecting the free surfaces, is only to  be solved
upon the ground of less resistance being offered in this direction.   The
said infiltration of parenchymata and  of  contiguous textures, is co-signi-
ficant with the oedema that surrounds patches of inflammation.
  To an indefinite distance beyond the range of true inflammation, and
lessening in intensity as the distance  increases, congestion takes place,
and with it the effusion of serum.  And the serum becomes, in like man- 
104
INFLAMMATION.
ner, poorer in plastic substances towards its periphery.   Such is inflam-
matory oedema; oedema encompassing the range of inflammation.
  The accompaniments of pain, redness, heat, swelling, are explicable as
follows:
  Pain is determined—
  1. In external injuries, as wounds, burns, cauterization, either by the
immediate action of  the cause of the inflammation upon the  peripheral
nerves, or else by reflection from the central organs.  In no instance is
it determined by the inflammation itself.
  2. By the pressure and  tension which the dilated and overladen ves-
sels, and the effused fluid exercise upon the nerves, true inflammatory pain.
  3. Finally, pain of a certain  degree, or rather of particular kinds, is
to be referred to augmented temperature in an inflamed part.   In the
absence of increased warmth, which characterizes certain inflammations,
pain is generally absent, also.
  The redness is a consequence of the overloading of the dilated capilla-
ries with blood-corpuscles;  it is therefore to be designated as the redness
of injection.   A new creation of bloodvessels does not,  as was once sup-
posed,  ever  accompany the inflammatory process  itself, and cannot,
therefore, be taken into account here.
  The  redness is also, in some measure, due  to the blood thrown out
during the stage of congestion and  stasis.
  In some inflammations, one great source of the redness is the drench-
ing of  the tissues with dissolved blood-pigment,—redness of imbibition.
  In form, the redness of injection varies in different textures, according
to the  order in which their capillaries are  disposed.   Take for example
the linear redness of  injection in inflamed fibrous  structures.   In the
most vascular structures, however, the naked eye is no  longer cognizant
of aught but a uniform red tint.
  Lastly, the redness is subject to many gradations of color, being deeper
in proportion as  the organ is vascular, and the  congestion intense.  Much
depends, moreover, upon the constitution of the blood,  and  more espe-
cially of its red  pigment;  take, for instance,  the  copper-redness of the
syphilitic, the violet hue of the typhous stasis.  The elevated, tempera-
ture has its  source partly in the formative processes, in which blood in
the condition of  stasis becomes  engaged, but for the most part in the ex-
citation produced upon the sensitive nerves.
  The swelling is dependent—
  (a.)  Upon dilatation and repletion of the capillaries;
  (b.)  More  especially upon exudation of blood-serum and plasma ;
  (c.)  Upon concurrent hemorrhagic effusion (extravasation).
  The two latter conditions give rise, in like manner, to the  loose, lace-
rable condition of inflamed textures.
  After this description of the inflammatory process, and this interpre-
tation  of its phenomena, we should  proceed to investigate the so-called
issues of inflammation.   These, however, resolution  excepted, cannot be
satisfactorily considered without an  insight into the various products of
inflammation, nor these products themselves be rendered intelligible but
by  a knowledge  of the manifold varieties and  anomalies of the process,
and of its relation to the blood-crasis. 
VARIETIES  OF  INFLAMMATION.
105
                    VARIETIES OF INFLAMMATION.

   Inflammation is characterized by much variety and anomaly.   On the
one side, it recedes so far from the foregoing description of the process,
that it has been attempted to distinguish certain forms as spurious in-
flammation.   On  the other side, its gradations into mere  hyperemia
and  a preternatural amount of plasma-exudation (nutritive irritation)
are so imperceptible, that discrimination becomes a matter of difficulty,
the greater, perhaps, that such processes frequently do become  exalted
into, and do alternate with, inflammation.
   Every hyperaemia may attain the point of inflammatory stasis.
   (a.) Active hyperaemia, the same in origin with inflammatory conges-
tion, is developed into sthenic, or active, inflammation.
   (b.) Passive hyperemia,—the result of direct, centrical or peripheral
palsy of the entire nerve-apparatus of  an organ,—becomes passive, as-
thenic inflammation.  To it belong, amongst others, all  hypostatic in-
flammations, occurring in dependent parts  during the progress of ady-
namiae and marasmi, and the asthenic inflammations  in organs paralyzed
by concussion, complex injuries, or by  direct central influence,—for ex-
ample, of  the bladder, in  paraplegia.  Many of them have  a humoral
origin, a dyscrasial disturbance giving rise to paralysis either central or
directly peripheral.  The hyperaemia  and stasis are characterized, in
the absence of pain and increased temperature, by very dark livid red-
ness, partly of injection, but for the most part of imbibition.  Their pro-
ducts, conformably with the humoral elements, are poor in coagulable
material, discolored by adherent blood-pigment, spuriously reddened, sero-
albuminous, sero-purulent.  Frequently the stasis becomes absolute, de-
generating into necrosis  of the blood and of the diseased texture; in one
word,  into gangrene.
   (c.)  Mechanical hyperemia, as  we have seen, commonly determines
exudation  of serum [oedema], and this not alone from the true capilla-
ries, but also from the larger veins.  By intense mechanical obstruction,
the hyperaemia is raised  to  a stasis marked by very deep redness,  great
tumefaction, numerous lacerations  of vessels, and  hemorrhage.   It de-
posits the  usual coagulable  products, but often degenerates, with  com-
plete paralysis of the organ affected,  into absolute stasis and gangrene.
   The course of inflammation is  acute  or chronic ;  all else being equal,
sthenic, and traumatic inflammations, and (amongst those  due to internal
causes) such as result from a fibrino-croupous crasis, are marked by their
acute  character.   Asthenic inflammations, on  the  other side,  and of
these, more especially the ordinary hypostatic, incline to a chronic course.
Chronic inflammation is variously modified.
   (a.) Inflammation may tarry unwontedly  long at any one of its stages.
It is in unison with the causal  conditions upon which  hypostatic inflam-
mations depend, that their stasis should be abiding.   The congestion is,
moreover,  often only very gradually brought about.
   (b.)  There are inflammations in which a  decided stasis is most proba-
bly never  arrived  at;  the process consisting in prolonged congestion,
with a slackening  of the circulation, bordering upon stasis.   Arrested
processes of this kind give rise to  exudations, poor in coagulable mate- 
106
VARIETIES  OF  INFLAMMATION.
rials, serous in kind, and prone to accumulate either by slow degrees or
by sudden impulses.
  (<?.) Chronic inflammation consists  in a  linked  succession, stage for
stage, of inflammations more or less acute.   Amongst  the most marked
are those occurring in the vascularized products  of  an antecedent in-
flammatory process, more particularly in the pseudo-membranous pro-
ducts of inflammation upon serous membranes.
  (d.) Inflammations productive of pus and ichor, whether of external
or internal origin, are, for the  most  part, essentially  chronic processes
imitative of a secretive function.
  In point of degree and extension, inflammations offer the greatest pos-
sible  variety.   For the  degree of intensity  of the inflammation,  the
intensity of the external appearances, especially redness and tumefaction,
together with the quantity and quality of the  products,  affords  a crite-
rion.   This, however, applies exclusively to  inflammations due  to local
external causes.   In inflammations kindled out of an  internal humoral
element, the mildness of  the stasis and of its symptoms is often strikingly
disproportionate to the quantity and character of its  products.   Even
the former kind is subject to frequent exceptions: thus, purulent exuda-
tion, which is commonly  regarded as the product of a very intense stasis,
not unfrequently  occurs in great abundance under slight symptoms.
  The extent of an inflammation, that is, its diffusion  over one or more
organs, depends both upon its occasional cause and  upon accessory  cir-
cumstances.  Inflammations evoked by dyscrasial  agency,  very com-
monly assault large  organs, or at least considerable sections  thereof,
very  frequently several  like-named  or kindred organs, at once, or in
rapid succession,—for example, serous, mucous,  follicular formations.
  Inflammation is not essentially modified by  anatomical differences of
organs and tissues.  We may here, however, remark that—
  (a.) Organs differ greatly in  the proneness  to inflammation from an
internal humoral cause, there being a certain relation of organs to special
erases.  Frequently,  however,  peculiar  extraneous impulses concur to
localize a crasis upon a particular  formation;  take,  for  instance,  the
localization of the  puerperal crasis upon the peritoneum, a part  enlisted
both in the act of parturition and in the puerperal uterine process.
  (b.)  Vascularized new growths, like normal textures, may become  the
seat of inflammation, luxuriate in growth, and  increase in  substance, or
else decline and perish.  Sloughing and luxuriance  of growth  are here
occasionally concurrent  processes.  Tender,  budding  formations  are
especially apt to become destroyed by inflammation, at the same time
that  a more vigorous germination is becoming established in their vicinity.
  The distinctive  characters of regeneration and of suppuration,  de-
structive inflammation, will be considered under the head of Terminations
or Issues.
  Both the causes and the products of inflammation constitute very im-
portant grounds of  distinction, and a  rigid discrimination is necessary
between inflammations from external, and inflammations from internal
causes.  To the former class belong not alone the inflammations locally
engendered by direct  external  influences, but  also those awakened in
remote but sympathetically allied formations, through  the mediation of 
DYSCRASIAL INFLAMMATION.
107
the nerves.   To the  latter class  belong those hyperaemiae and stases
based upon a greatly  overwrought condition  of the nervous centres, be
it irritation or paralysis, and more particularly inflammations arising out
of a pre-existent dyscrasial or humoral element.

        RELATION  OF THE INFLAMMATORY PROCESS TO CRASIS.

   A  twofold relation exists between inflammation and  an anomalous
crasis, the latter being either a mere result of the inflammatory process
and secondary, or  else pre-existent and primary, and the inflammation a
consecutive, symptomatic phenomenon,—the localization of the  crasis.
   1.  The undeniable  development of a dyscrasial condition of the blood,
as the sequel to mere local  inflammation  produced by external and, it
may be, traumatic influences, justifies the inference that inflammation is
in itself a dyscrasial process.  All doubt as  to this point is,  however,
overcome if we consider—
   (a.) The qualitative variations in the products of a local inflammation;
and still more—
   (b.) The fact that,  where the blood is  in  the condition  of stasis, the
elements of the exudation are found preformed within the vessels.   The
character of the products is thus shown to be  mainly dependent  upon
inbred transformations of the stagnant blood, and more  particularly of
its plasma.
   Inflammatory stasis is thus shown to be no mere passive congestion;
effusion to be no mere percolation of an altered plasma simply  divorced
from  the blood-globules.   On  the contrary, both are shown  to imply
every variety of conversion, from simple exaltation of the formative pro-
cess carried on in normal plasma, to the generation of totally heteroge-
neous combinations and of corresponding form-elements.   For  the same
reason the plasma  effused, and  the fibrinous  matter thrown  out as the
result of inflammatory stasis, differ from  mere  extravasated  plasma, or
extravasated fibrin.   The same arguments, in fine, serve  for the solution
of  the  question: in what wise  does  an  anomalous constitution of the
entire blood-mass result from local inflammation ?
   Consecutive dyscrasy, as infection of the blood, is brought about—
   (a.) Through direct readmission of  effused  matter into  the circulation
by endosmosis, or through the indirect way of  resorption through lym-
phatics ;
   (b.) Through a more copious reception  of  the  products  of inflamma-
tion into bloodvessels laid open by external injury, or by ulceration and
necrosis;
   (c.) And (besides these commonly-taught channels) through the ebbing
back  to the roots of the veins of the altered plasma, issuing from blood-
vessels involved in  the process of inflammation.
   This  last mode  of infection is decidedly the most common.   It is,
indeed, the only one  possible  where  endosmosis  and resorption of the
substances effused are, owing to the density of the latter surpassing that
of the lymph or of the blood, excluded.  It resembles, on a small scale,
that infection of the blood due to inflammatory products directly thrown 
108
DYSCRASIAL INFLAMMATION.
out into the cavities and canals of the circulation from their  internal
membranes.
  The interest and the practical importance of the subject warrant us,
whilst  referring to the chapter on  blood diseases and on pyaemia, in
remarking here that,—if we except cases engendered by very heteroge-
neous  substances,  the result of decomposition within  or  without the
vessels,—infection stands in direct relation to the magnitude and number
of the inflamed parts, and, as a consequence, to the amount of inflam-
matory products taken up into the blood.   In opposition to a fermenta-
tion theory, we may affirm that a minimum of inflammatory product does
not suffice to determine a perceptible alteration of its  admixture, very
small quantities merging in the normal processes of the circulating mass.
The most pregnant source of infection is the inflammation of the internal
membrane of bloodvessels.
  The character of the infection and  of the  consequent crasis corre-
sponds with that of the products of the inflammatory stasis.
  Consummated infection of the blood-mass bears towards every inflam-
mation which it may subsequently  call forth,  the relation of a primitive
crasis localized in congenial inflammation.
  2. In  every crasis,  hyperaemia and  stasis may occur  accidentally.
Here, however, we are more particularly concerned with inflammations
resulting from a special crasis as their internal and sole cause.   To this
class belong a multiplicity of anomalous erases, more especially, however,
the fibrin-crasis and pyaemia, the former being usually comprised under
the so-called phlogistic crasis.  Inflammations dependent  upon dyscrasial
impulses are marked by their preference  for  particular  organs,  and, for
the most part, by the acuteness of their career, as  well as by  the  rapid
formation of their products.
  This last  circumstance is, to a certain  extent, practically demonstra-
ble with respect to the fibrin-erases and pyaemia.  In these, the exami-
nation of the blood shows that, the same changes occur in its totality, as
in any portion of it in the condition of stasis; that both  the plasma and
the fibrin  are constituted  identically  with the products of the stasis.
Herein a source is supplied for the rapid development of the stasis, and,
consequently, of the effusion.   In the  stasis, a simple increase of the
processes  carried on in the totality of the blood suffices to furnish forth,
in exquisite form, a characteristic exudation.
  Inflammation of humoral origin is determined, according to the neuro-
pathological theory, by antagonistic palsy of the  nerves  of the blood-
vessels, brought about, at  the periphery  or  at  the centres,  by the
irritating effect of  the dyscrasial blood upon the sensitive nerves;   or, if
passive, by direct paralysis.  To such inflammations unquestionably be-
long  many commonly  ascribed to  an external cause; for  example,
pneumoniae.   These we believe  to be, for  the most part,  the localization
of a crasis modified by atmospherical influences.
  The relation of the crasis to particular domains of the nervous system
determines the localization of certain erases in particular organs, almost
as a definite rule.   Still, the modifying power of concurrent  external
influences is not to be lost sight of.
  Inflammation  arising out of humoral  elements manifests  itself not 
EXUDATION.
109
unfrequently as a metastasis, exhausting the  crasis and resolving itself
into a local evil.
  The above becomes invested with greater significance when applied to
the exudatory processes upon which  the production of various  hetero-
logous formations rests.

                             EXUDATION.

  The greatest and  most marked differences  of inflammation are mani-
fested in its products.  In inflammations due to a pre-existent crasis,
such difference is intelligible enough,  the product of the stasis having its
germs, in part at least, preformed in the general circulation.  It is less
clear with  respect  to  inflammations devoid  of a  pre-existent crasis.
Mere local inflammation,  however,  independent  of  any dyscrasial mate-
rials, will yield products  presenting a repetition of many, if not of all,
the characters which mark the products of dyscrasial inflammation, such
as  simple  (plastic) fibrinous  exudation, fibrino-croupous (pyin-holding)
exudation,  pus, ichor.   Here the question is: wherein are the different
characters  founded ? how  elicited by stasis out of normal matter ?   Their
ultimate source can be no other than the  stasis itself, of which it might be
predicated—
  (a.) As  stasis it promotes, and,  within its  range, condenses upon in-
considerable elementary materials,  the  changes and formative processes
which take place in the general circulation.
  (b.) When feeble  in  intensity it determines mechanically the display
of thin, serous, sero-fibrinous, sero-albuminous substances, poor in plastic
materials.
  (c.) Greater intensity and  duration occasion relatively, through the
continued  afflux of  oxygen to a given quantity of plasma engaged in
stasis, excessive fibrin formation, and ulterior  oxidation  of the  fibrin.
Hence result fibrinous exudation, and,  as  a higher degree of oxidation
of the protein (Mulder),  croupous  constitution of the fibrin,  croupous
exudates, pus- and ichor-exudates.
  (d.) Absolute  stasis, deficiency  of oxygen, leads to necrosis  of the
blood and of the  implicated textures,—gangrene.
  The exudate  is, accordingly, now of general, now of local  import.
Exudates, when formed, suffer various  changes through external influ-
ences, and take various  impressions not inherently  theirs;  thus not
unfrequently entering  upon  anomalous modes of  development.  Like
blastemata, they  do  not exude unalloyed;  croupous fibrin and pus, for
example, being always mingled with a certain  amount of so-called plastic
fibrin and normal plasma.   Nevertheless, the study of exudates in their
utmost simplicity of  forms is indispensable.
  Exudates, indeed, both in  their primitive  condition, and  in the
changes which they undergo, irrespectively of impressions from without,
afford an insight into the  local processes occurring in blood involved in
stasis, as also into the processes carried on in  the general circulation,
that is to say, into the crasis itself.
  The most instructive of  all exudates are those occurring upon serous
and mucous membranes, upon  which  many, if not most, erases are wont
to localize. 
110
EXUDATION.
  The doctrine of inflammatory exudation is, in many points, applicable
to the products of other processes  of exudation, nor  shall  we, in the
sequel, neglect the opportunity of generalizing in this sense.
  Let us pass, in the mean time, to the enumeration of exudates  as esta-
blished  according to anatomical  research, taking at the  same  time, a
general survey of the various changes which they undergo.
  1. Fibrinous  exudation comprises several varieties, each correspond-
ing to a particular constitution of the fibrin of blood involved in stasis,
or of the general  circulation.   They are, for  the most part, not pure,
one kind being  always alloyed with a proportion,  however  minute, of
another kind, and a certain amount of normally constituted fibrin attach-
ing to all.                                              .
  (a.) Simple or plastic fibrinous  exudation.—A   grayish, yellowish-
gray, or if containing  blood-corpuscles, even red, reddish-gray exudate
which, in great  part,  speedily solidifies, into bulky,  membranaceous,
plug-like, or frame-like coagula, whilst the remainder, where the  propor-
tion of blood-serum is considerable, coagulates  in the latter  into flocculi,
thus parting into a solid and a fluid constituent.  It  presents itself, on a
closer inspection, as a clodded, fibrous, diaphanous blastema, of very
tenacious properties, the broken surface of which is felt-like and studded
with nuclei and nucleated cells.   It  answers to fibrin 2.  It is observed
in its purest form in wounds, when  these agglutinate  and heal by the
first intention.   Besides this, it occurs  upon the pleura, in areolar tissue,
in muscles, in bones, upon the endocardium  and the  internal bloodvessel
membrane, in the brain, occasionally, as pneumonia, in the parenchyma
of the lung, which  either slowly recovers its natural state through ab-
sorption, or ends in induration with extinction of the pulmonary texture.
Upon serous membranes it constitutes the peripherous coagula lining the
inner surface of  serous sacs.   It frequently enters, in  common with a
certain proportion of normally constituted fibrin, into the composition of
other exudates, as that portion of them upon which  a change  of  texture
depends, for example,  into the croupous, the purulent, &c.
  The following are its metamorphoses, the most remarkable amongst
which is its textural conversion.
  (a.) It becomes  partially or wholly reabsorbed;  this occurs  slowly,
through the instrumentality partly of the serous portion of the exudation
itself, partly of a supplementary effusion of serum, succeeding to the
resolution  of the  stasis.  These humors furnish  the solvent—the cor-
roding media,  so to speak, for the solidified fibrin effused, having incorpo-
rated which, layer  by  layer, either  in  solution, or in a  state of minute
subdivision, they  forthwith become reabsorbed.   In like  manner, the
fibrinous coagula within  the vascular system;  for example, vegetations,
thrombi, &c, are progressively taken up again into the blood.
   (/3.) It wastes and hardens,  with  the loss of its  fluid part and with
lessening  of its volume, to a horny,  and eventually,  perhaps, to an
ossified mass.
  (r.) It undergoes a change of texture, commonly, and for the greater
part, consisting  in an ulterior development  of  that fibrillation of the
blastema which  ensues upon  the solidifying of the  exudate.   To avoid 
EXUDATION.
Ill
repetition, we refer for the details of this  process to the heads—New
Growth of Areolar Tissue, and Fibroid Formations.
  In rare instances, the new formation of bloodvessels is predominant
therein, more especially in exudates upon the arachnoid membrane.  In
the vicinity of serous membranes, there result serous layers, a new serous
sac; in contiguity with bone, bony texture.
  The time requisite for these transformations is  scarcely definable in
a general way.   Under favorable circumstances, they are wont, even in
voluminous  exudates, to attain an advanced or nearly completed state,
within the space of six weeks.
  The constitution of the exudate  corresponds, as before stated, with
that of fibrin 2, having either been acquired in the stasis or pre-existed
as a blood erase.   It is a  quantitative anomaly consisting in an exagge-
ration of  the formative processes which occur in normal plasma,—and
especially in the locally and  generally increased  generation of a fibrin
(hyperinosis) marked by its coagulable and plastic properties.
  (b.)  Croupous   exudation  has several  varieties, dependent upon  a
qualitative impairment of the fibrin.   It is, with the utmost impropriety,
confounded with the former and  its  kindred erases.  It is marked by a
high degree of  coagulability;  by  a yellow, or greenish-yellow coloration;
by  its opacity; by its inorganizable nature; by its  early tendency to
break  down, to  liquefy;  frequently by a corrosive, texture-softening
power.   The quantity of  serum  simultaneously thrown out is  relatively
insignificant.
  The croupous process of exudation and  its product are further dis-
tinguished,
  1. By the commonly excessive, exhausting, quantity of the  exudate,
and its extension over wide ranges of organs and textures.
  2. By the rapidity with which the effusion is brought about, where the
stasis depends upon a pre-existent crasis.
  3. By the often slight vascularity of the diseased texture;  a circum-
stance due, it may be, to the blood-corpuscles not appearing prominently
in the  opaque, over vigorous  plasma, or else to the exudate, by its ex-
cessive quantity, soon leaving the bloodvessels exsanguine and collapsed.
  4. By less adhesiveness.
  5. By considerable fattiness of the exudate.
  The principal metamorphosis of the croupous exudate  is the aforesaid
breaking down, and liquefying to a fluid more  or  less analogous to pus,
which constitutes the so-called liquid, purulent exudate.
  This metamorphosis first of all affects the solidified blastema interven-
ing  between certain form-elements of the exudate;  only in  an adhe-
rent portion of  organizable fibrin does  the  latter undergo a change of
texture—namely, to areolar  tissue.   When liquefied, it may be wholly
reabsorbed,  or  may leave a  residue in  the shape  of a fatty, curd-like,
cretaceous pap, or, lastly, of a glutinous fluid, abounding in free fat and
in salts of lime (in elementary granules, granulated  cells, cholesterine
crystals),  which speedily thickens into a cretaceous concrement.
  (a.)  Croupous Exudation, an  abundant, proportionately to its con-
tents in blood-globules or in blood-pigment, more or less red (red hepati-
zation of  lung), or grayish-yellow mingling with green, opaque exudate, 
112
EXUDATION.
consisting of a sod-like, fibro-laminated, or striated membranous base-
ment, a large proportion of dotted substance, nucleated formations, dull
granulated nuclei and nucleated cells.  The nuclei are  not influenced by
acetic  acid, beyond  some little shrivelling, together with  a sharpening
of their contours.  This answers to the constitution of fibrin 6.   It.lique-
fies first in its basement  mass, with change of texture  of any adherent
portion of organizable fibrin, to a pus-like fluid.
  (/S.)  Croupous  Exudation.  The  above-mentioned characters,  espe-
cially the opacity and the greenish coloration, are  here more strongly
developed.   It consists, together with an amorphous blastema, of nucleus
and cell-formations, more or less akin to  pus-nuclei and pus-cells, and of a
predominating quantity of granulated substance.  It adheres  loosely to
the exudation-surfaces and deliquesces rapidly.  It answers to fibrin 4.
  These exudates occur most of  all upon membranous  expansions, upon
mucous membranes (as the well-known croup), upon serous and synovial
membranes, and in  the substance of the  lung.  Again, they occur in
areolar tissue, in the pia mater, in the convexity of the cerebral hemi-
spheres, upon the endocardium and the internal bloodvessel membranes,
in  parenchymata, and upon the  surface of both internal  and external
sores.   Almost all the pneumoniae, except those ending in slow resorption
or induration of their product, belong to  this class, and pre-eminently
those in which the lung becomes enormously distended with a  very copi-
ous, rapidly deliquescent yellow effusion, the  stage of  red hepatization
being,  in Hodgkin's opinion, here altogether wanting.
  As the exudates break down,  they exert,  especially after long-con-
tinued contact, the aforesaid corrosive  liquefying influence upon their
substrata,  occasioning ulcerous  loss  of substance, pulmonary abscess,
destruction of serous membranes, ulcerous perforation of  the thoracic,
the abdominal, parietes, &c.
   (y.)  Croupous Exudation.—Aphthous  Exudation,  a yellow,  green-
ish-yellow,  dingy-grayish,  opaque  product, wont, upon surfaces,  to
solidify into tough membranes, and then melt down, reducing  the impli-
cated textures to the same condition.  This said  product consists some-
times in simple destruction of the textures, sometimes in a  blending into
a variously discolored, fetid, ichorous pulp, or into a  tenacious, greasy
slough, which tears like tinder.
   These exudates affect, with especial frequency, the mucous membranes,
particularly those of the alimentary canal, of the urine bladder, of the
female sexual organs, with  their follicles; secondly, external sores and
ulcers; thirdly, the  common integuments.   Under this  head belong
thrush or  aphthae, diphtheritis,  exudates upon  the  intestinal  mucous
membrane of the intestines, and of the colon in particular as represent-
ing one form of dysentery, and of the uterus after childbirth ;  corroding
exudates upon external and internal  wounded and ulcerated surfaces, for
example, on the base of the typhous ulcer, white gangrene of the com-
mon integuments, hospital gangrene.
   Croupous exudation  is occasionally the product of  an intense inflam-
matory stasis, unconnected with any pre-existent crasis. It is, however,
much  more  frequently the  product of  a stasis  in which  the croupous
 crasis has  suddenly become localized.
   (c.) A special form of fibrinous exudation is the tuberculous—the true 
EXUDATION.
113
fibrino-tuberculous.   It is a repetition both  of simple,  and, when en-
gendered by inflammation, of croupous exudation.   It is characterized by
a proneness to tarry long in  its primitive, crude state, and eventually
to soften down.
   It exudes  almost, if not wholly, pure, or else blended with a certain
proportion of organizable fibrin.  In the former case it  represents a
homogeneous gray, or  yellow,  curd-like,  brittle,  fissured  mass;  upon
serous membranes, a similar uniform layer, of  uneven stellate  surface.
In the second case,  the tuberculous  matter is imbedded in the  shape of
more or less crowded tubera clusters, or larger  masses, within the  other
portion  of the effusion, which has attained to various grades of  textural
development.  In the last-mentioned  case, more  especially, tuberculous
exudation is, upon serous  membranes, always characterized  by clustering
of the granules.
   Tuberculo-croupous exudation affects serous  and mucous membranes,
evincing a preference for those of the bronchial, of the alimentary, canal,
of the uterus, and of the  cavity of the tympanum.  It invades the paren-
 chyma of organs at all points, but most of all that of  the lungs, as infil-
 trated tuberculous pneumonia of the lobar, or still  more commonly the
 lobular form, the substance of lymphatic glands ; lastly, the interior of
 follicles, and particularly the Peyerian capsules.
   There are cases in which it may be but the local produce of a stasis.
 More commonly, however, this stasis is itself a localization of the tubercle
 crasis,  and  the tuberculous exudate the prodcct of general dyscrasial
 processes.
   2. Albuminous exudation  occurs united to  a proportion of fibrin as
 a fibrino-albuminous; or as a mere  albuminous; or again,  mingled with
 a certain proportion of serum, as a  sero-albuminous exudate.
   Albuminous exudates  are marked by their fluidity,  by their tenacious,
 ropy consistence, often by their abundance.   They are colorless and re-
 semble a thick synovia;  or milk-white and  opaque;  or again blended
 with croupous fibrin and of a yellowish-white.  Their  turbidness, and
 also their thick porridge-like  nature, are due  to their  quota  of form-
 elements (elementary granules, nuclei, cells),  to their proportion of fat,
 and to fatty conversion (granule-cells); or again, they are  due  to an act
 of coagulation, the albumen assuming, by virtue of a chemical conversion
 of the  entire  exudate, the coagulate form.  Coagula of this  kind are
 for the  most part  soft, flocculent, forming, upon  serous membranes,
 velvety deposits,—not  unfrequently as the inner coating to a periphe-
 rous fibrinous coagulation.
   The form-elements, present in various  amount in the albuminous exu-
 date, are identical  with  those found in the fibrinous exudate, nucleus
 and cell exhibiting  themselves in  multiform variety,  ending  with the
 perfect pus-cell.
    It is very rare for albuminous exudates to assume  at once—that is,
 immediately on becoming effused, the solid form.
    The changes which albuminous exudates undergo,  vary  with the cha-
 racter  of the albumen.    In the one case, they  enter into a progressive
 transformation of texture, which in  fluid albumen obeys—in solidified
   vol. i.                           8 
114
EXUDATION.
albumen evades—the laws of the cell theory, thus determining hyper-
trophy of the areolar tissue, and induration and extinction of the paren-
chyma, for example, in the lungs.  In dyscrasial constitution of the albu-
men, on the other hand, they have a decided tendency to liquefaction, to
fatty conversion, whereby they  become  either fitted  for resorption, or
endowed with a corrosive power.                             .   .    .
   Their appearance is for the most part connected with a crasis, involv-
ing either  a  simple predominance of albumen (deficiency of fibrin) in
the blood, or concurrently a dyscrasial condition of the former.   To the
first description belongs, for instance, the  venous diathesis (Venositat),
the  concomitant  of heart disease, of infancy, and of extreme age, of
atrophy, of defibrination.  The  products are  represented  by colorless,
adhesive, pasty exudates, poor in form-elements, and,  owing to the often
low intensity of the stasis, largely diluted with serum;—sero-albuminous.
To the second description belong the erases which attach to cutaneous
affections, to  typhus and the like,  with their dull whitish effusion;  and,
again, the anomalous quality of albumen  pertaining to the fibrino-croup-
ous crasis, to pyaemia and the like, with their pus-like effusion.  The
stases are often of the asthenic or hypostatic kind, and run a protracted
course.
   3.  The serous, dropsical exudate.
   Serous effusions are, generally speaking, either merely serous (blood-
serum) ; or again from their containing a larger proportion  of albumen,
albumino-serous; or, lastly, owing to  an  admixture  of fibrin,  fibrino-
serous.  This gives rise to several important distinctions in their physical
bearings.   The mere serous effusion is a thin, watery, limpid, colorless,
or pale yellowish, now and then  reddish-yellow fluid, salt to the taste,
and containing  little, if  any, albumen.   A large proportion of albumen
renders it tenacious, like a thin synovia.   An admixture of fibrin mani-
fests itself upon serous membranes as a peripherous coagulum of incon-
siderable thickness, as a villous deposit, as a filamentous, wide-meshed,
network or finely membraned honeycomb, or as a flocculent cloud within
the serous fluid.  Or again, it may, in the shape of the so-called spurious
fibrin, which  solidifies tardily, perhaps only after cooling and coming in
contact with the air, appear in the effused serum as soft, jelly-like, trans-
parent, coagulate pellets, which are often found lodged within the afore-
said  true fibrinous network, or honeycombed structure.  Fibrino-serous
effusion may be said  to be invariably the  product of an inflammatory
stasis.  It is simply fibrin-exudate,  with a  notable  preponderance  of
serum.  It might well be denominated fibrinated dropsy.
   Albumino-serous  effusion is sometimes, like that previously described,
the product of a not very intense, often of a protracted, stasis or simple
congestion.   As an example, may be cited the (inflammatory)  oedema,
encompassing the range of an inflammation.   It occurs more commonly
independent  of the latter, in  the albumino-serous crasis,  as  general
oedema.
   Mere serous effusion is the result of an excess of serum in the  blood—
the serous crasis; or else it is the product of acute and more frequently
of chronic hyperaemia.   In  the latter case, the effusion  seems to origi-
nate less from the capillaries than from the small thin-membraned veins. 
pus,  icnoR.
115
  It represents genuine dropsy, and  does not at all imply  a foregone
  inflammatory stasis.
     Serous effusion,  as such,  is not  organizable.  Albumen  and fibrin,
  however, when blended with it in sufficient quantity, are susceptible of
  a  somewhat tardy, structural change.   It  relaxes and tumefies the
  textures on becoming imbibed, destroys their contractility, and by long-
  continued  contact  exerts,  more especially upon the muscular fibres, a
  remarkable power-bereaving influence.
     4.  Purulent and ichorous  effusion.   These  range immediately with
  fibrinous and albuminous  exudation, as also with their fibrino-serous,
  albumino-serous combinations.  Purulent effusion seems, however, to be
  more especially akin to the fibrino-croupous exudate.
     The importance of these products renders  it desirable to discuss them
  at greater  length.

                               PUS, ICHOR.

     No product of disease has, perhaps, been  the subject of such zealous
  research as pus  and ichor, and yet nowhere has  a greater number of
  shortcomings been overlooked or glossed over than here.   These we
  may  be  incompetent to remedy; we may, however, render some slight
  service to  pathology if we can succeed in simply directing attention to
  them.
     There are so many kinds of purulent-looking fluids,  and  there is so
  great an affinity of these fluids amongst each other, that, for the sake of
  discrimination, it is indispensable to establish one standard form of pus.
  Such a  standard form is furnished  in  the  pus of granulating, healing
  wounds,  as well as in that of certain abscesses.
     This normal pus is a homogeneous, cream-like, fatty, glutinous fluid,
  of a  yellowish color, of a flat, sweetish smell and  taste,  of a specific
  gravity of  from  1030  to  1333 (Vogel), and when  recent,  of alkaline
  reaction.
     It  consists essentially of pus-serum, with certain form-elements, these
  being, besides molecular granules (elementary granules),  the pus-nucleus,
  and  the  pus-cell.   To these is  to be added the pus-placenta, of which
  more hereafter.
     The pus-cell is a spherical or oval—now  smooth and even, transpa-
  rent,  thin  membraned—now  granulated and opaque,  nucleated  cell,
s  which, under a magnifying power of 400 diameters, appears colorless,
  or faintly yellow, and measures from T^ to g'oth of  a millimetre in
  diameter.
     Its granulated  nucleus, firmly attached to the cell-wall, is,  in  the
  translucent cell, visible without the  aid  of artificial expedients.   In the
  granulated cell, on  the contrary, it is rendered indistinct, if not totally
  obscured, by the contents  of the cell, but is  readily discernible on  the
  application of acetic acid.   It generally occupies from  one-half to two-
  thirds of the cell's cavity,  and in  rare instances almost  fills  it  up.
  Generally speaking, it is single ; not unfrequently, however, it is mani-
  festly composed of from  two to five smaller corpuscles.  Normal  pus
  only rarely contains larger cells, with two, three, or four nuclei.   Under 
116
PUS,  ICHOR.
 the action of acetic acid, each pus-nucleus being brought out with sharper
 contours, as a spherical (according to Vogel, cupped) body, presents the
 well-known characteristic phenomenon of indentation and eventual split-
 ting.   In other words, the nucleus, after passing through sundry modi-
 fications of shape, down to that of  a trefoil, finally breaks up into two,
 three,  or four sharply-defined corpuscles, no further soluble  in  acetic
 acid.
   Besides the cell-inclosed nuclei there are present free nuclei.   These
 are in  like manner either single (perfected), or made up of from two to
 five corpuscles, and they exhibit the same  phenomenon  of indentation
 and splitting, when treated with acetic acid.
   The  molecular granules are present in various numbers, some  scat-
 tered, others grouped together.
   The  contents of the cells  are in  some cases limpid, in others, owing
 to very minute granulations, nebulous.  It  is very common to find one
 compact group of pus-cells presenting every known gradation in the
 quality of their contents.
   The  development of the pus-cell is easily  demonstrable, falsifying the
 assertion  that  the  nuclei are artificially produced by chemical agency.
 For the most part from two to five of the larger molecules  associate
 themselves into a group, and constitute, thus aggregated, an imperfect
 nucleus.  By and by they coalesce, and  present  a simple,  finished nu-
 cleus—a fabric reducible, by the agency of acetic  acid, to the very same
 elements.
   The  nucleus now becomes surrounded, often immediately, with a cell
 wall, so closely fitted  at first,  as to  require  the  endosmotic agency of
 water, or dilute acetic acid to disconnect it, and render  it cognizable.
 Many nuclei, however, become previously endued with a delicate nebu-
 lous deposit, which  by and  by puts  on a circumscribing cell-envelope,
 and assumes the contour of the  cell.
   These formations are, to a  greater or smaller  extent,  always dis-
 cernible in genuine pus, in the  progress of germination.
   Cells devoid of nuclei,—clear, transparent cells, which have to create
 a nucleus out of their own materials, are rare.
   The  phenomena of  endosmosis and exosmosis bring out  the pus-glo-
 bules with great clearness.
   The chemical relations of  the pus-cell are not without their weight in
 reference to its constitution,  and to its recognition.
   Dilute  acids, for  example, dilute hydrochloric, oxalic, tartaric, but
 especially acetic acids, have the effects of tumefying, loosening, attenua-
 ting, bursting, without entirely dissolving the pus-cells, whilst upon  the
 nuclei  they produce the above-mentioned appearance, first, of greater
 distinctness of outline, then of indentation, and lastly, of disruption.
 . „™tlc  alkalies aQd  their carbonates convert  the pus-cells into a
jelly-like, granulated substance.
   Thin solutions of certain saline substances, as for instance, of chloride
 oi sodium  hydrochlorate of ammonia, nitrate of potash, iodide of potas-
 sium, with many others, cause first the disappearance  of the  sheaths,
 and secondly, the swelling  up of the nuclei into a shapeless grume
   A solution of borax acts like the alkalies, only less rapidly   Metallic 
PUS,  ICHOR.
117
salts, alcohol, tannic acid, &c, which coagulate fluid albumen, render
the pus-globules shrunken, nebulous, and opaque.
  In the blood, in  urine, in  mucus, and in saliva, the pus-cells are pre-
served unchanged; bile, on  the contrary,  occasions a disappearance of
the sheaths, and a bloated aspect of the nuclei.
  From  these facts, and from further experiments in the same direction,
Lehmann and Messerschmidt draw the following conclusions :
  1.  The sheath of pus-cells, turgescent in acids, soluble in solutions of
caustic alkalies,  and of their saline conjunctions, is identical with a pro-
tein-compound which may be artificially produced out of albumen, depo-
sited by water, and redissolved  by alkaline  salts, and acetic  acid—a
modified albumen, poor in salts,  constituting a transition stage  to fibrin
—fibrin a.
  2.  The nucleus, insoluble in acetic acid, soluble in solutions of alkalies,
turgescent in solutions of salts,  a protein-compound similar to the venous
fibrin, turgescent in salines—fibrin b.
  3.  The third substance, namely, the molecules accompanying  the pus-
cells, forming part  of the contents of the opaque granulated cells, and
even exhibited  in the nuclei (the nucleus-corpuscles of  Lehmann and
Messerschmidt), are uninfluenced by alkalies or borax, and are regarded
by Lehmann and Messerschmidt, as a substance analogous to the  essential
constituent  of horny texture.  They, however, partly consist, as Vogel
rightly maintains, of fat.
  Besides these  elements, pus not unfrequently contains  cholesterine-
crystals,  crystals of ammonio-phosphate of magnesia, animalcules, &c.
  Like  Henle, we  have been unable to satisfy ourselves of the above-
mentioned effect of alkaline  salts or of borax solution.  In the changes
wrought by the application  of thin solutions, we recognize the pheno-
mena of  endosmosis down to rupture  of the  sheath of  the pus-cell; in
the changes  wrought by the application of saturated solutions, a shrivel-
ling thereof.
  The pus-serum in which, when at rest, the pus-cells  gravitate, has the
composition  of blood-serum,  with  some difference, however, in the  rela-
tive proportions of its constituents;  fat, for example, predominating.
With respect to pyin, to which we shall  afterwards have to  recur, our
belief is that it is not a constituent of normal pus at all.
  Pure pus  we believe to be an  albuminous exudate, out of which, like
other elementary bodies, the  pus-cell becomes developed by virtue of a
specific conversion.   This process, the so-called  development of pus out
of fluid blastema, occurs upon surfaces—upon mucous membranes, upon
the external skin, upon open wounds, in abscesses.   This  pus  exudate,
however, enters  frequently into combination with fibrinous exudates of
different  kinds.
  Of these, we could first mention the combination with the fibrino-croup-
ous exudate, because  this furnishes the  base  of the  so-called  develop-
ment of pus  out of solid blastema.  Whether, or how far, we participate
in this view, will appear in the  sequel.
  Both upon surfaces and within parenchymata, a solidifying  fibrinous
blastema is frequently thrown out.  A careful inspection will show, im-
bedded  in the solid basement, as also floating  in  the sero-albuminous 
118
PUS,  ICHOR.
 fluid, molecular granules and genuine pus-nuclei and pus-cells.   Together
 with these are always found a few nucleus and cell-forms, which vary in
 their relations, more especially to acetic acid.  The solid basement mani-
 fests itself as croupous fibrin, which liquefies, incorporates the aforesaid
 elements, and is distinguished by its great abundance of the most minute
 molecules.  This combination of pus with fibrino-croupous  exudate, con-
 stitutes the so-called solid pus,  or the pus-plug, and is  that upon  which
 the breaking down, the softening, of inflammatory induration, abscess,
 and the like depend.  The  pus-cell  is always developed out of the sero-
 albuminous moisture pertaining  to the fibrin-exudate, never out of  or at
 the expense of the latter itself, the liquefaction of which implies a meta-
 morphosis.   This pus, in virtue of its constituent, croupous fibrin, con-
 tains pyin.
   Another combination of the  pus-exudate, is  that with plastic  fibrin
 exudate.  This  frequently,  but not invariably, furnishes in pus the basis
 of  new solid textures, of regeneration, of the cicatrix.   The fibrin-exu-
 date determines the pus-placenta.
   Pus may, without impairment of  its primitive character, present vari-
 ous anomalies, for example:
   (a.)  Watery pus; the pus-cells having become bloated in the preternatu-
 rally thin medium.
   (b.)  Preternaturally saturated pus-serum, as containing more saline
 and albuminous matter.   The pus-cells appear  less turgescent, smaller,
 shrivelled, denticulated.
   (c.)  Pus which has  become acid exhibits the nuclei  more distinctly,
 more sharply defined, and, it may be, in a slight measure ruptured, within
 a transparent membranous sheath.
   (d.)  Various admixtures,  as blood, mucus, epithelial, and other textu-
 ral debris.  It is to be remarked, however, that, by certain admixtures,
 for instance, of faecal matter, of decomposed urine,  and again by its acid
 conversion, pus  may become transformed into a corrosive  fluid, and its
 secreting texture goaded into the production of ichor.
   The nearest approach to pus is found in broken-down fibrino-croupous
 exudates.  It has  been seen that these frequently enter into a combina-
 tion with true pus-effusion, and  the  liquefaction of the  fibrino-croupous
 elements m pus-effusion constitutes what  is termed the  development  of
 pus out of a solid blastema.  Broken-down, pus-like,  fibrino-croupous exu-
 date is always marked by its fluid  parts holding in suspension a large
 proportion of the most delicate nebulous molecules, and is distinguished
 from pus by the relations of the  coexistent nuclei and cells.   These  exu-
 dation elements, namely, manifest, as we  have stated, on the one hand,
 an insensibility towards acetic acid, under the influence of which  by an
 evident condensation and shrinking, the cell-walls and  contours of the
 nuclei  are brought  more distinctly into  relief;  or it may  be that the
 cell-walls and cell-contents are rendered clearer,  whilst  the nucleus be-
 comes  condensed and more sharply defined.
   On the other  hand, these cells approximate to the character of the
pus-cell, the nucleus exhibiting, with the disappearance of the cell-wall,
to  a various extent the phenomena of denticulation and splitting.  It is
in  our opinion, the   broken-down fibrino-croupous exudate, either alone 
PUS,  ICHOR.                        119
or blended with true pus, that constitutes the pyin-holding pus form.  It
has been stated that these pus-like exudates frequently manifest a corro-
sive, deliquescent influence upon the textures.   Not being  organizable,
they are extremely prone  to  further decomposition, and to assume the
nature of ichor.   They furnish  forth the majority of cases of  internal
suppuration, of constitutional pus deposits, of abscesses.
   Ichor, which, in broken-down croupous exudates,  often  closely resem-
bles pus in appearance, is distinguished from the bland nature of true pus,
by its corroding influence upon the textures, and upon the form-elements
developed out of  its protein substances.   It is only under such a state of
things that a fluid can be recognized as ichor.  That met with after death
varies infinitely.  A chemical examination of it embodying what is essen-
tial, and simplifying what  seems  differential, is still wanting.  Its degree
of corrosiveness varies equally.   Ichorous exudates are now thin, serous
fluids; now albuminous, viscid, limpid or flocculent,  emulsive and  fatty,
thickish,  colorless,  or  yellowish, yellowish-green,  puriform,   whitish,
creamy.  Or, owing to  the presence of blood-corpuscles and  of blood-
pigment, they are of variously shaded red, dingy brown, greenish-brown,
chocolate-colored.   Again,  they are ammoniacal,  hydro-sulphuretted,
rancid  or sour-smelling, acid or alkaline, and apt to  produce upon the
skin of the dissector a tingling  or  smarting  sensation.  These fluids,
minutely examined, are  found to contain variously sized elementary gra-
nules, down to the finest molecular mass, nuclei and cells, of  the  cha-
racter of exudation and pus-cells, partly stunted in their development,
partly owing to the saline, alkaline, or acid  condition of the ichor,  shri-
velled, jagged, lax, diffluent, the  pus-nuclei being in the act of denticula-
tion and splitting.
   They further contain fibrinous coagula of various kinds, in  different
grades of spontaneous reduction into pulpy masses, coagula out of casein
and pyin substances.
   Finally, they yield crystalline salts and textural  debris in the act of
breaking down, blood-corpuscles, animalcules, &c.
   Even ichor  enters into combination with fibrinous exudates, especially
the fibrino-croupous; and, just as in the case of pus, there is, besides the
fluid product ichor, another ichor developed out of consolidated  blastema.
Having now described both pus and  ichor, this appears to  us  a proper
place for the establishment of certain marks necessary for a due discri-
mination between the two.
   The bland properties  of normal pus are acknowledged ; but how does
this characteristic tally with the manifest destruction of tissues implicated
in the  formation of pus ?   The  following remarks  may tend to throw
some light upon this point:
   (a.) The destruction attendant upon pus-exudation  is limited to ne-
crosis of the textural elements involved.   But this necrosis is due to the
intercepted supply  of blood and to forcible disjunction; not to that che-
mical corrosion and  that resolution of the textures which result from ichor-
ous discharge.
   (b.) That the bland nature of  pus is so frequently questioned, arises
from products being so often regarded  as pus, which  are not  so in
reality, and which either originally possessed, or have acquired the pro- 
120
PUS,  ICHOR.
perty of corrosiveness.  Such products very commonly form the contents
of shut abscesses.  Normal pus very often acquires a corroding property
through long 'seclusion within abscesses, which, when opened, forthwith
secrete a normal, bland pus.
   One of the most remarkable phenomena in the process of suppuration,
is the formation of flesh granulations.  These granulations present, with
reference to their character and further  development, two marked dis-
tinctions :
   (a.) They consist, together with a small proportion of intercellular or
bond substance, of primary cells.  These cells emerge, together with the
pus-cells, from  a common albuminous blastema, and  out of them  are
called forth, conformably with the laws of the cell theory, those elemen-
tary fibrils which ultimately compose the cicatrix.
   (b.) They consist of a  fibrinous  blastema which,  exuding  conjointly
with  the  pus,  solidifies upon the suppurating surface, and yields, by
immediate splitting, the fibrous texture of the cicatrix.  Into both these
scar-bases enters a new generation of bloodvessels, answering to those of
abiding suppuration.  They determine  the healing  of wounds  by  the
second intention.
   The formation of flesh-granules  is not decisive evidence of a bland,
benignant pus.   It may accompany, and even luxuriate under, the pro-
duction of ichor.  In the one case, however, the granulations are marked
by their durability, and by their further  textural development, whilst in
the other, they form but to be corroded and redissolved by contact with
the ichorous fluid.
   Flesh-granulations accompanying the production  of pus  in or upon
heterologous growths, have, for the most part, the significance of  textu-
ral elements of such growths.
   The tendency of pus (and of ichor) to  vent itself  externally, is com-
monly overrated.  Pus deposits are often deeply encysted within organs
and a passage to without often needs to be made artificially, in order to
prevent the fluid from burrowing.
   The assertion that extensive exudates are especially liable to become
converted into  pus, is ill  founded, if  magnitude of the exudate be the
assumed condition of such conversion. Doubtless what led to the opinion,
was the liquefaction of the commonly very massive  croupous exudates,
together with the circumstance that pus-blastema, either pure or com-
bined with croupous fibrin, very often becomes effused in great quantity.
Apart, however, from quantity, the puriform quality of an  exudate is
invariably due to inflammatory stasis. This alone, and not the quantity,
 can determine  the development of the elements of pus.
  ^ Purulent and ichorous exudates are met with not alone in  the  locali-
 ties assigned to normal pus.   They often occur in great quantity upon
 serous and synovial membranes, and in  areolar tissue, more especially
 the subcutaneous and submucous,  as also  in certain of the more lax,
 deep-seated collections of this tissue, for example, in the mediastina, in
 the posterior  circumference of the caecum, around  the rectum, and the
 like.  Lastly,  they take place upon mucous membranes,  within  soft
 parenchymata, and in bone.
   The following are the  metamorphoses which the said exudates, if not
 excreted, undergo: 
PUS,  ICHOR.
121
  (a.)  Transformation of texture, appearing, after the process above
described, in the form of so-called granulations.
  (b.)  Bissolution affects both the form-elements (cells, nuclei), and the
fluid intercellular substance, in the shape of various unknown chemical
transformations.  Under  this head may be  brought the septic decompo-
sitions, suffered by  these exudates under  peculiar  circumstances; for
instance, through long stagnation, through contact with the atmosphere,
through the  effect  of medicinal  substances, and the like.   These  may
cause the  degradation of bland pus into ichor, and of ichor a step lower
in the  scale.
   (c.)  Fatty conversion in the formative process of granule-cells, fre-
quently combined with the simultaneous  deposition of the salts of  lime,
(cretefaction).
   (d.)  Resorption.
   The manifold ways in which pus substantively, or as pus-serum, enters
the circulation, and there occasions pyaemia, cannot at all concern us  here.
They  were before  adverted  to,  and will be further and  more amply
noticed under the head of Pyaemia.
   Here we have to consider the  resorption  of  pus in a more  restricted
sense,  and irrespectively of pyaemia.
   This resorption can apply only to the  serum or plasma  of pus.   To
pus or ichor in their totality, that is to say,  their form-elements included,
it can  only apply after they have undergone liquefaction  or fatty  con-
version.  Upon the mode of liquefaction  depends, in the case of pus, the
nature of the consecutive phenomena.  If it consist in a putrid  decom-
position, the noxious effects of septic poisoning of the bood  may ensue.
   Pus  may  either  become completely  reabsorbed, or leave within its
former nidus a residue of fat in the shape of discrete or aggregate fat
molecules and  cholesterine crystals, within a glutinous fluid,  or in the
shape  of chalk incrustation and concretion.
   The depot of pus  and of ichor  (abscess) heals, through the subsidence
of pus  and ichor production, and  through the organizable products of in-
flammation existing in the walls of the abscess, with new supplementary
ones,   undergoing  transformation into vascularized textures.  Pending
this act, the contents of the depot are  in the manner before specified,
entirely or partially reabsorbed.   According to the measure of resorp-
tion, the walls of the abscess  shrink together and ultimately  coalesce into
a solid cicatrix, or else include an inspissated fatty or chalky, or lardo-
cretaceous residue of the primitive contents.
   Pus  and ichor are the product, at one  time of a mere local inflamma-
tory stasis, at another time  of a localized  pre-existent crasis, namely,
general pyaemia.   In the latter case, the production is characterized by
the rapidity of its occurrence.
   Suppuration in open abscesses  and upon granulating sores is peculiarly
chronic in its course. This process manifests itself as a protracted stasis,
communicated from the original textures to  the  embryonic  new growths
which  the granulations  with their newly acquired vascular apparatus
have given rise to.   Taken in another point of view,  the  granulations
appear to  stand to pus-formation  in a relation which earlier pathologists
signified by the terms pyogenous  membrane, a pus-secreting apparatus. 
122
HEMORRHAGIC EFFUSION.
Looking at the often slight intensity of the inflammatory symptons, the
analogy between a granulating wound (abscess) and a  secreting  organ,
—between pus and  a secretion prepared by  those elementary bodies,
cells, appears so great, and the current comparison with a mucous mem-
brane and its product so apt, as forcibly to recur to us, even  at  the
present day.   Thus, no sooner have the growths which presided over the
secretion—in other words, the granulations—become exalted into  tex-
tures, than the secretion itself fails.                       #
  Referring certain particulars connected with the anatomical  doctrine
of exudates to the head of crasis, we have still to  consider, as kindred
with ichorous exudates,  diffluent exudates, and with them  hemorrhagic
effusion.
  (a.)  Solvent exudates.  Akin to ichorous exudates, they are marked
by their destructiveness to subjacent textures,  by the obviously solvent
character  of their effects, and by the absence of any outward tokens to
denote their mischievous character.
  These are products which,  owing to the corrosion of textures accom-
panying the very act of their exudation, are rarely to be  met with in
their simplicity, products which display immense variety in their  physi-
cal properties.  As the extreme limits of a long  series, we find, on the
one side, a coagulable, fibrinous exudate which has the effect of slightly
corroding  the subjacent membranous substance.  On  the other side we
have a thin  exudate,  variously discolored, which reduces the textures,
extensively, to a dingy brown, chocolate-colored, inky (hemorrhagic), or
greenish, pulpy, tinderlike, fetid, slough.   This last-mentioned exudate
represents the processes which Boer described  in the uterus as putres-
cence,  a term  quite  deserving of  application to the same condition in
other parts.   Midway between these  two extremes, we  encounter the
most remarkable—however seemingly  insignificant—thin,  serous, sero-
albuminous, tenacious,  paste-like,  sero-purulent,  almost  colorless, or
again  yellowish,  reddish-yellow,  exudates, in contact with  which the
textures are resolved according to  their degree of injection, into a pale,
or into a more or less deeply-reddened pulp.
  Their seat, always diffuse,  is most particularly the mucous membrane
of the  intestinal tract, and most commonly of the colon, not rarely of
their follicles (in the shape of diarrhoea or dysentery), and, lastly, of the
uterus, as puerperal  affections following childbirth.  Of the principle
upon which this liquefiant destruction of the tissues depends, nothing is
known beyond its frequent acid reaction, nor has any crasis  correspond-
ing to  it been recognized.
  (b.)  The hemorrhagic exudate.
  It is indispensable in the first place to discriminate between exudates
reddened by blood-pigment  only,  and  those which contain substantive
blood,  that is, blood-corpuscles.
  The former are met with in all dyscrases, both acute and  chronic, in
which, owing to defibrination, to decomposition of the fibrin, or to dimi-
nished proportion of salts, blood-pigment is transferred from the  blood-
corpuscles to  the blood-serum.   Thus, exudates  occurring during  the
progress of scurvy, of typhus, of gangrene, of  the drunkard's dyscrasis,
ot putrid exanthemata, are stained with adherent blood-pigment.   Those 
HEMORRHAGIC  EFFUSION.
123
containing blood in its totality, and the red color of which results from
blood-corpuscles, are the true hemorrhagic exudates.
  Holding fast this distinction, we shall be enabled partly to infer from
physiological reasoning, partly to prove by the exact method, the origin
and import of hemorrhagic effusion.
  We have seen that, in every inflammation, at the  stage of congestion
and stasis, there occur extravasations of blood, proportionate  in extent
to the vascularity of the organ, to the magnitude of its congestion and
stasis, and lastly, to the laxity and vulnerability of its texture.   That this
bleeding takes place out of lacerated, or in somewise opened vessels by
extravasation, and not by transudation, is evident  from the absence in
the walls of bloodvessels  of pores equal to the transudation of blood-cor-
puscles.   This  is the  rule with respect to hemorrhage in textures like
those of the brain or the lungs.   The difficulty is, and always has been,
to explain hemorrhagic effusion occurring upon serous membranes,—a
formation so given to  effusion in no way hemorrhagic.   Upon this point
it is to be observed :
   (a.) A primitive  genuine hemorrhagic exudate (not merely blood-
stained), if it really ever occur upon serous membranes, occurs only as
a rare exception.
   (b.) Hemorrhagic exudates upon  serous membranes  are, almost with-
out exception, the result of hemorrhage from the bloodvessels of a spuri-
ous membrane in the  act of becoming organized ;  in other words, from
the product of a previous inflammation of  the serous tunic.  This hemor-
rhage may be an independent act, or it may be the concomitant of in-
flammation propagated from the serous coat to its pseudo-membranous
duplicate.  This is, in fact, usually the case.  Such exudates are secon-
dary  ones.
  The facility with which hemorrhage takes place from these new growths,
is explicable on the  ground  of their imperfect organization,  both  as
regards change of texture and  the  development  of bloodvessels.   An
inflammation early set up in  such  a new formation, encounters a lax,
soft,  lacerable  growth, involving an  incomplete,  soft,  and delicately
membraned vascular apparatus, with anastomoses as yet unclosed ; blood-
vessels which, when urged into congestion and stasis, readiy give way,
or possibly force a passage from  their free and as  yet  unanastomosed
ends into the substance, and through this  into the cavity, of the serous
membrane.
  Accordingly, under  these stereotype conditions, hemorrhagic exuda-
tion is precisely what  extravasation is during the course of an inflamma-
tion in the laxer textures, namely, exudation plus hemorrhage.
  Hemorrhage being, however, the consequence not alone of mechanical
laceration, but also of a softening or  a corrosion of the vessels, it is intel-
ligible how ichorous exudates, and the solvent exudates generally, may
put on a hemorrhagic character.
  Hemorrhagic exudation seems to stand in an especial relation to tuber-
culosis, and is dreaded chiefly because the latter is assumed to be its source.
It is important to be clear upon this  point:
  (a.) It is quite true that it is very frequently a partially tuberculized 
124
ISSUES OF INFLAMMATION.
new growth (pseudo-membrane) in which the hemorrhagic process occurs.
Still there are very notable exceptions to this.
  (b.) Tuberculized  growths appear  to be peculiarly liable  to  inflam-
mation ; tubercle being wont to set up reactive processes of inflammation
everywhere in its circumference.
  In this  way the hemorrhagic inflammatory process often concurs with
local tuberculosis, without directly depending upon the tuberculous crasis.
That tuberculosis acts as the source of hemorrhagic  effusion is rendered
probable by experience, but it is by no means proved.
  In like  manner, hemorrhage and hemorrhagic exudation break forth
in the midst of carcinomatous growths, or in pseudo-strata, of the same
character, upon mucous membranes or within serous sacs.
  In quantity, the extravasate mingling with the exudate varies consi-
derably, and it may be either  intimately blended both with the coagula
and with the fluid portion of the exudate,  or separated  from  it in the
shape of pellet-like clots.
  Apart from'the aforesaid conditions of its appearance, and of its rela-
tion to  tuberculosis, it is of evil omen only in  proportion to the loss
of blood entailed by it,  and to the previously  reduced vital strength
of the patient.
  The hemorrhagic exudate is not  organizable,  or only very tardily so.
This refers more particularly to the exudate ; the blood-corpuscles after
long remaining unaltered at length  become dissolved, leaving  their pig-
ment to undergo the  changes elsewhere described.  The exudate portion,
answering to the character of its base, very  commonly retains its rudi-
mental condition, which in  the majority of  cases  is tuberculous.
  It would seem advantageous, before  concluding,  to  revert  to  a few
points already touched upon, relative to the habitudes of exudates in and
upon diseased structures.
  Exudates are deposited more or less uniformly between the elementary
parts of textures.   This is contingent  upon the more or less uniform
density and cohesion of the  textures, as also upon the number of bloodves-
sels present, and their mode of distribution ; for example, the striated exu-
dates, following the  linear arrangement of the bloodvessels in tendons
and ligaments.
  When copious effusion takes place suddenly and violently in the laxer
structures, for  example, in the  brain, the  exudate  becomes established
through the forcible  separation and  laceration of the natural textures.
  In the inflammation of membranes the exudate is, as we have stated,
for the most part thrown out upon the free surface.   In the  inflamma-
tion of glands  similar effusion takes  place into their respective  cavities—
the uriniferous tubules, Malpighian bodies,  and the like.
  Coagulable  exudates solidify upon the surface  of inflamed membranes,
and are commonly termed spurious membranes.  Upon serous membranes
they occasion  agglutination of the serous surfaces.

                     ISSUES  OF INFLAMMATION.

  The so-called issues of inflammation comprehend a variety  of pro-
cesses.  They concern either the inflammation itself or its products and 
ISSUES OF INFLAMMATION.
125
the involved structures ;  that is to say, they embrace, in the latter rela-
tion, the changes which both the inflammatory products and the textures
themselves undergo.
   To the former category belong:
   1. Resolution or dispersion of the inflammation.
   To the second belong:
   2. Reliquefaction and resorption of the inflammatory products.
   3. Abiding of the inflammatory products in various forms, including,
amongst others, the issue in induration, and in inflammatory hypertrophy.
   4. Suppuration, ichorous, ulcerous destruction of textures.
   We cannot ourselves regard suppuration as an issue of inflammation.
Wherefore we have treated of pus and ichor as of products of inflamma-
tion, under the head of " exudates."
   Of the issue of inflammation in gangrene, of so-called inflammatory
gangrene, we cannot well treat separately.  We therefore refer the con-
sideration of this point  to  a  subsequent chapter, to  be devoted to the
Bubject of gangrene.
   1. Resolution of the  inflammation.—Issue in  resolution relates  di-
rectly to the inflammatory  process.  It consists in a  cessation of the
latter, previously to any act  of  effusion;  that  is, in a  reduction of the
existing stasis.
   As determining conditions, we may adduce:
   (a.) Cessation of the efficient cause of inflammation ;  and, as a conse-
quence, cessation of the palsy of the bloodvessels, and returning contrac-
tility of the latter.
   (b.)  Reinforced impulse from the  arteries,  brought  about by the said
contractility of the capillaries, one effect of which is a return of the pheno-
menon of oscillating motion in the arrested blood-column.
   (c.)  Liberation of the blood-corpuscles from a  state of mutual cohesion,
through endosmosis of the exuded blood-serum into the vessels charged
with concentrated plasma.   The  blood-corpuscles lose the flattened con-
dition and  deep color which they had acquired in  the stasis, swell out,
and become spherical and at the same time paler.
   (d.)  The uninterrupted  circulation in the  capillaries surrounding an
inflammation,  plays its  part likewise,  portions of the stagnant blood-
column being (according to Emmert) forcibly separated by the laving
current, and a passage forced here and there through an entire capillary
range.
   Obstacles sometimes present themselves to the resolution  of inflamma-
tion ; and  even when the process is  accomplished, certain residua are
left behind:
   (1.) The blood-corpuscles are so firmly wedged in the dilated capilla-
ries, as to resist  both the contraction of the latter and the  increased
impulse  from  the  arteries.   This occasions  a protracted stasis  of a
mechanical nature.
   (2.) Even  after removal of the stasis,  a certain degree of palsy and
dilatation of the capillaries may remain entailed.  The part previously
inflamed continues in a  state of hyperaemia, and prone to relapse into
inflammation.  This tendency  increases greatly upon  repetition.  The 
126
ISSUES OF INFLAMMATION.
resolution of local inflammations dependent on external  causes, is com-
mon only where these causes are slight.
   Inflammations dependent  upon internal dyscrasial  influences rarely
terminate thus.   An essential  condition of their so doing is the extinc-
tion of the dyscrasis.   If without  this the inflammation take  such an
issue, it will localize itself in other organs  standing in  the relation of
sympathy with that originally affected.
   Even this favorable  consummation of the inflammatory act is not a
matter of indifference for the  organism, seeing that plasma, altered by
the  previous stasis, is  copiously received back again into the  blood.
The consequences  are  obvious, and directly  commensurate  with the
extent of the inflammation.
   2.  Reliquefaction and resorption  of the inflammatory products.—
This issue of inflammation is contingent upon  previous exudation, and
consists in resorption of the products.   It takes place with greater or
less facility, according to the measure  of the exudation, and to its degree
of solidification.  It  succeeds either  completely  or incompletely,  and
hereupon it depends, whether in the sequel the  diseased organ  recovers
its normal condition altogether, or only partially and imperfectly.
   Fluid exudates are naturally susceptible of resorption.
   Solid exudates become adapted for resorption  by preliminary solu-
tion,—corrosion through  blood-serum,—or else by disintegration, with
various changes in their chemical composition.
   Elementary bodies must be  previously dissolved, in  order to become
adapted for  resorption, which  process  takes place both through the
bloodvessels and the lymphatics.
   The consequences of  resorption differ with  the primitive quality of the
exudate, with the mode of its  preliminary solution and of its chemical
transformation, and with the quantity reabsorbed.  Finally they differ
accordingly as the resorption takes  place chiefly through the lymphatics
or directly into the sanguineous current.
   In this issue  of inflammation is comprehended wasting of the textures
through inflammation.  It consists  in  the elements  of the textures being
themselves liable to become reabsorbed along with the products of inflam-
mation.  This is owing  to the textural elements, within the range of in-
flammation, becoming functionally  disabled  by  mechanical pressure, to
the  impediment to their  nutrition  offered by the  effusion; the  result
being the  dissolution and resorption of those elements.  This termina-
tion is especially frequent  in  delicate,  vulnerable textures,  in  very
copious effusion, and where the latter, being solidified, is susceptible only
of very tardy resorption.  In this manner is  the substance of the brain,
of muscle, of kidney, and the like, destroyed within the range of inflam-
mation, its  place becoming  occupied  by a  cavity, or by multilocular
cavities bounded by scar texture. Where these are  small and numerous,
they beget a loosening,  a rarefaction of the textures, as, for example, in
the condition termed cell-infiltration in the brain.   In hollow structures,
for example the Graafian vesicles, the contents, altered by the exudate
and its metamorphoses,  are absorbed, and the organ becomes extinct.
   3. Abiding of the inflammatory product.—The products of inflamma-
tion  are retained bodily, or after imperfect resorption, partially, in their 
ISSUES OF INFLAMMATION.
127
original, or it may be in  an altered shape  and constitution.  Confor-
mably with what has been stated, the exudates continue—
   1.  In their original crude state, as entirely amorphous masses, or more
commonly in  a condition bordering upon this, of incipient textural de-
velopment, in the shape of molecular granules, of nucleus and cell-for-
mation, or in  the case of consolidated blastemata, in the laminated and
fibrous structure  engendered by the coagulative process itself.
   2.  Or they break up sooner or later, and abide in a state of final cre-
taceous or fatty conversion.
   3.  Solid exudates waste away, and condense and shrivel into a horny
substance.
   4.  They become  organized, attaining thus to  various grades of  de-
velopment.  In fluid exudates this development follows the laws of the
cell theory, whilst, in the organizable, solid, fibrin-exudates it  consists in
immediate fibrillation through dissilience*
   The exudates  enter,  bodily,  into a  uniform textural change.   This
change may, however, conformably with the frequent primitive impurity
of blastemata, be in many cases unequable.   One portion of the exudate
may attain a higher gradation and represent permanent textures,  whilst
another may be  arrested at  an embryonic stage, and there liquefy and
become reabsorbed, or, like  pus and ichor, qualify itself essentially for
excretion.
   A textural  conversion of exudates may be of a nature very similar to,
if not identical with, the normal structure, in its anatomical, chemical,
and functional relations.   Or, again, it may  involve one or more hetero-
logous formations, pus and cancer, for instance.
   It is more particularly areolar tissue, and  the  various fibroid textures
tending to the final composition of the latter; cartilage in the process of
ossification ; and bone with its penetrating vessels, that are here referred
to as organized products of inflammation.
   These often serve to compensate for lost parts, as also for the  filling
up of vacant spaces wrought by the retraction of normal textures after
injuries, regeneration in  muscles for instance.
   The regeneration  is complete ;  or it is imperfect, being accomplished
by means of a texture  not homologous with the lost one,—as in the
cicatrix.   This, again, may be permanent, or it may be provisional  only,
and about to disappear  after becoming  endowed  with  textural elements
identical with  the normal ones,—the nerve-cicatrix, for example.
   Where permanent exudates do not  serve for compensation, they  occa-
sion an increase of mass  in the diseased organ.   They  are then—
   (a.)  Uniformly interposed between the elements of the normal texture.
This determines an inflammatory hypertrophy, which, perhaps, occurs
in a genuine form only in areolar tissue and in bone.
   (b.)  Or they form in a larger circumscribed mass,  distinct from the
normal texture,—a  tumor.  These local collections  of cicatrix texture
occur in muscle  (the heart)  and in all parenchymata.   Upon serous
membranes, they  constitute the various organized pseudo-membranes and
membranaceous adhesions.   We have here further to remark:
   1. In bulky, and particularly in solid, wasting exudates, or such as
are in progress of transformation into dense, shrivelling (fibroid) struc- 
128
GANGRENE,  NECROSIS.
tures, any textural elements which they have embraced become atrophied
by pressure and tension, hindrance to their  nutrition, and  the suppres-
sion of their function.   Even  contiguous  textures waste away, owing to
arrested or impaired function—for instance, the muscular  apparatus of
respiration over thick, resistent, shrivelling, pleuritic effusion.
  2. In hollow  organs  the  abiding  of exudates not rarely occasions a
hypertrophic development to  cystiform dilatations, with transformation
of the texture of their walls and contents.  As examples, we may refer
to the  degradation of glandular acini, and  of the  follicles into cysts.
(See Cyst.)
  3.  Solid exudates  determine, through  increased  consistency  and
density of the textures previously inflamed, the issue of the  inflammation
in so termed induration.  On the other hand, the abiding of soft liquid
exudates results in relaxation, softening, lacerability of the textures.
  4. Exudates are often found to linger under several combined forms,
with which, moreover, both resorption and suppuration may have con-
curred.
  4.  Ulceration, Ichorous destruction.—It consists in a wasting of the
textures from  the corrosive  quality of the  exudate.  Herein ulcerous
consumption of the textures differs from the loss of substance which in-
flamed textures undergo, within the best  conditioned exudates, through
necrosis and absorption.
  To be productive of such a wasting process, the exudate must needs
be fluid, whether originally  so, or liquefied out of a solid blastema.   Its
corrosive influence upon the textures is sufficient to confirm its character
as genuine ichor.
  The mode in which textures in contact  with ichor  become destroyed,
varies with the principle upon which its corrosive nature depends.  The
exulceration takes sometimes an acute,  sometimes  a chronic course.
Large textural masses are not rarely  destroyed within a short space of
time.   The destruction is marked, now by superficial extension, now  by
a burrowing propensity.  In the former instance, it  depends frequently
upon a special relation of the  inflammatory process to superficial textu-
ral  expansion.   In the other case, some heterologous formation, repro-
duced again and again, at the base of  the ulcer, upholds the inflamma-
tion, and with it the ichorous  discharge.
  In the chronic form,  the  ulcer, like the pus-membrane, simulates,  in
the production of flesh-granules, a natural process of secretion.
  All textures are not equally prone to ulcerative  destruction.  Under
like circumstances, tender, young, budding growths are the most readily
destroyed.

                        GANGRENE, NECROSIS.

  Under gangrene, necrosis, is understood the death of an organ or part,
as manifested by the more  or less rapid breaking down  and  chemical
decomposition of its texture.  Gangrene may affect both soft  and solid
structures, the bones, for instance, or even fluids, as in necrosis or sepsis
of the blood.   The breaking down of solid structures, is generally a slow
process, whilst in soft, juicy textures,  and in fluids, it is  rapidly con- 
GANGRENE,  NECROSIS.
129
 summated.   Like  normal textures,  new  formations  of every  kind,—
 tumors, exudates, pus,—are liable to become necrosed.  Fluids  degene-
 rate through necrosis to gangrenous  ichor, the most infectious and  de-
 structive of its tribe.
   A general characteristic of gangrene is  not  easily given, so manifold
 are its forms, and so various its causes.   Soft  parenchymata commonly
 break down to a diffluent pulp, marked by a high degree of discoloration
 and of fetor. Exceptions are, however, numerously afforded in gangrene
 of the bones, mummifying, white gangrene.
   Gangrene has the import sometimes of a local, sometimes of a symp-
 tom of general disease.   The conditions necessary to the former case
 are nearly reducible to arrested afflux of blood, that is,  stasis.   It may
 begin  by attacking fluid parts, and especially the blood,  and extend from
 these to solid structures, or it may affect them all at once.
   Gangrene is developed—
   1.  Out of absolute blood-stasis, which may  occur under various  cir-
 cumstances :
   (a.)  Every hyperaemia in organs, or  sections of organs, paralyzed or
 enfeebled, or obnoxious to debilitating influences, may  degenerate into
 absolute stasis.   This applies particularly  to asthenic, hypostatic hyper-
 aemia  in torpid  peripherous organs, vegetating, so  to say, imperfectly
 under the embarrassment of continued pressure.
   (b.) Mechanical  hyperaemia frequently  becomes  absolute  stasis, as
 observed in incarcerated, strangulated organs,  and as a  consequence of
 extensive plugging of the returning vessels in the lower extremities.
   (c.)  Every inflammatory stasis may  degenerate  into absolute stasis,
 more  particularly  those  hypostatic  and  asthenic inflammations which
 occur  in organs already diseased, paralyzed,  or  depressed by  violent
 external  influences, such as  concussion, contusion,  cold, or heat.   An
 inflammation consequent upon influences directly  or indirectly debilita-
 ting, may acquire, during its progress, a tendency to absolute stasis.
   In absolute  stasis, the blood  undergoes  gangrenous  decomposition.
 Hence the blood is the portion originally  necrosed and dissolved.  It
 exudes in a state of gangrenous decomposition, and in the form of ichor,
 through the walls of bloodvessels,  engendering  the same  gangrenous  de-
 composition both in these and in the surrounding  textures.   This event
 gives rise to the most ordinary and most developed  form of moist gan-
 grene, in  which  the textures are, through the medium of the  blood,
 broken down to a dark-colored, friable and lacerable, diffluent, and highly
 fetid pulp. The dark discoloration, however, of gangrene thus developed,
 is subject to various modifications due  to  certain elementary products,
 which  the inflammatory stasis has  generated both within the bloodvessels
 and without.
   The progress of this gangrene is more or  less acute, the gangrenous
 dissolution of tissues, already referred to  under  the term  putrescence,
 being particularly marked by the rapidity  of its course.
   2. Gangrene is determined by failure in the supply of blood:
   (a.)  In impermeability of large arteries,—high  degree of coarcta-
tion, and  complete  obstruction—consequent upon arteritis  and ossifica-
tion.
  VOL. i.                           9 
130
GANGRENE, NECROSIS.
  Here the gangrene, for the most part, takes the form of comparatively
dry, black, mummifying gangrene.
  (b.)  As the result of the immediate compression and tension of a part;
for  instance, in incarcerated hernia.
  (c.)  As a  consequence of the local  destruction of bloodvessels, the
denudation of parts of attaching and blood-supplying textures,—bones,
for  example,  of their external and internal periosteum; the common in-
teguments, of their supporting  areolar  tissue; the peritoneum,  of its
subjacent layers; isolation of the pulmonary pleura over cavities  of the
lung.
  The gangrene appears as a white or yellowish-white slough.
  To  this category  belongs the necrosis  of smaller textural parts,
loosened mechanically by exudation or by ulceration.
  (d.)  Extensive impermeability of the capillaries  and minute vessels
when plugged with  coagula, or compressed by surrounding exudates.
  In the last-mentioned case, the gangrene is dependent upon inflamma-
tion.   To this kind of  gangrene, textures poor in bloodvessels, such as
compact bones, callosities, &c, are especially obnoxious.   The  color of
the necrosed  textures differs with the different nature of the coagulation,
and of its exudate.   Answering to the  croupous  character of bulky
exudates, the textures involved in the necrosis commonly assume a yellow
or yellowish-green hue.
  3. The gangrene is the expression, the localization of an anomaly in
the  blood-erase, either directly ingrafted  by  infection (contagion), or
developed out of other erases; a putrid decomposition of the  circulating
fluid.  Blood so poisoned, especially if brought into  stasis or into  coagu-
lation, possesses, in common with the exudates  thrown out by it,  an in-
herent tendency to gangrenous dissolution.
  It has been already stated, that several  varieties of gangrene are re-
cognized :
  1.  Gangrene developed out of an internal cause is distinguished, by
the designation of primary gangrene, from  that  arising  out of  a  pre-
dominant external cause.
  2. Hot, acute, inflammatory gangrene.— True gangrene.   In what
wise inflammation leads to gangrene, is sufficiently clear from the fore-
going.
  (a.) The inflammatory  stasis, owing to its very intensity, to  pre-
existent debility of the diseased  textures, or, lastly, to  weakening influ-
ences  exercised during its progress, degenerates into  absolute stasis.
  (b.)  It occasions gangrene by the  crushing effect of its products upon
the  capillaries, or by the mechanical or ulcerous isolation of textural
parts.
   In the first case, the necrosis affects more immediately the blood held
in stasis; in the second, the textures.   In the  first case the gangrene is,
as it were, an immediate issue of the  inflammation, the opposite to reso-
lution ; in the  second it is a remote consequence thereof.
   In this way, gangrene may arise in tissues laboring under the sequelae
of inflammation, without being itself an  issue of the latter.
   3. Cold gangrene, sphacelus, is so-called, as being unconnected with
inflammation. 
GANGRENE,  NECROSIS.
131
  4. Moist gangrene comprises  the  breaking down of fluid substances
to gangrenous ichor, and  of fibrin  textures to a variously discolored,
diffluent pulp, marked h$r its evolution of fetid gases.  It is the gangrene
developed out of absolute blood-stasis;—therefore,  again, inflammatory
gangrene.   It may be compared to the decomposition of animal  matter
under the co-operating influence of water.
  5. Dry  gangrene  is a  consequence of deficient  blood  supply.   It
manifests itself in the perishing  of the implicated textures, with shrivel-
ling or withering thereof, to an incipiently tough, but eventually sloughing
mass.   Often, and  particularly  in the gangrene termed senile, which
affects the  extremities, especially the inferior, owing to impermeability
of their arteries, the gangrenous textures blacken ; wherefore this species
has been designated as mummifying gangrene.   As  such, it is compa-
rable to the decaying of organic matter, that is, to  decomposition with
absence or insufficiency of moisture, and with  the  disengaging  of pure
carbon.  Dry gangrene is frequently called gangrenous slough.
  6. Black gangrene, gangrenous slough.
  7.  White gangrene, gangrenous slough, occurs, for the most part, as
a consequence of pressure in incarceration ;  of the denuding of membra-
nous  expansions of their subjacent textures, for example, as peritoneal
sloughing at the base of intestinal ulcers.   Again, it is generated by the
necrosis or death of textures replete with fibrino-croupous  exudates, or
of such coagulate exudations themselves.  This refers more particularly
to the common integuments, the mucous membranes, fibrous and areolar
tissue expansions upon wounded  and ulcerated surfaces.  To this head
belongs hospital gangrene.
  Of these different species of gangrene, several are often concurrently
present.   Beneath  the  common  integument, often transformed into  a
swarthy  parched rind, in senile  gangrene, we frequently meet with
patches in which the textures are reduced to a humid stinking pulp.
  Just as gangrene of the solids, gangrenous slough, varies, so in like
manner does  gangrenous  ichor, as  necrosed  blood or exudate  vary,
according to the crasis  or constitution under which either has  become
attacked with gangrene.  Thus the necrosis  of typhous blood differs
from that of pus-blood,  or of fibrino-croupous blood.
  Like normal  textures,—diseased  textures and new  growths, fibroid,
cancerous formations, for  example,  may become a prey to gangrene.
Neither to ulceration nor to gangrene are all textures alike obnoxious.
Bony, elastic, fibrous textures resist gangrene more  ably than  muscle,
areolar tissue, or mucous membranes.  Lax  embryonic textures, as,  for
instance, certain kinds of cancer, are  especially prone to  gangrenous
destruction.
  The constituent elements of gangrenous texture-masses are, more  or
less  well-preserved  textural debris,  larger or  smaller black-contoured
molecules down  to a pulverulent granule mass, black and brown pigment
granules, fat-drops and crystals, saline crystals.
  Contact, reciprocity of action, with the atmosphere, is by no  means
indispensable  to the  generation of  gangrene.   It  affects equally with
the external parts, organs never in contact with the air, as the liver and
the spleen. 
132
INFLAMMATORY TEXTURES.
  A very important phenomenon involving a curative act, is the circum-
scription of gangrene by an inflammatory process of ulceration,—isola-
tion  of the gangrenous part through its own  secretion.   The  ultimate
healing is brought about by the  same inflammatory process changing to
one of pus-production, and of regeneration.

  CHARACTERISTIC OF  INFLAMMATORY TEXTURES AND DIAGNOSIS OF
               INFLAMMATION  IN THE DEAD SUBJECT.

  In the period  preceding  the  real exudation, an organ is, within  the
range of the inflammation, reddened, injected; that is, more than ordi-
narily vascular, swollen, and at the same time relaxed, softer, lacerable.
The  redness must be that of injection, and is to be  carefully  discrimi-
nated from redness of imbibition.   The swelling and relaxation result
from infiltration of the texture with exuded blood-serum.
  Generally speaking, the swelling is  accompanied by increase of volume;
to this, however, spongy textures, and in particular the lungs, are excep-
tions.   In  protracted,  and especially in hypostatic stases, the  swelling
of the texture frequently  occasions closure of the pulmonary cells, and
renders them inaccessible  to atmospherical  air.   The volume of the in-
flamed part falls short  of the normal.
  As, however, mere hyperaemia occasions similar appearances,  although
in a minor degree, the question arises : " What  are  the criteria in  the
dead body  which  justify us  in  pronouncing the  inflammatory  stasis to
be attained?"
  The only true criterion in the dead subject is afforded in the changes
suffered by the blood in the capillaries of the implicated  texture, during
the inflammatory stasis—changes cognizable, in part,  by the naked eye.
  Effusion having taken place, its product, exudate, affords incontestable
evidence of inflammation, wherever its character is  such as we  know by
experience to attach solely to the fruits of this process; examples  are
pus  or croupous  fibrin.   The redness  and  injection  cannot here com-
monly apply, having,  for the  most part,  given way  to the  effusion.
Even the swollen condition of the texture may in a great measure have
subsided during a mortal collapse.  The  relaxation of the tissues still
lasts, taking, however, in  solid exudates, the form rather of fragility, as,
for instance, in the hepatized lung.
  Where, however, the exudate  is a  blastema, well known to  exude both
with and without inflammation, the question arises : what circumstances
warrant us in  assuming such blastema to be  the product of inflamma-
tion ?  Such circumstances are—
   (a.) Rapid and copious production of the blastema ;
   (b.) The concurrence of exudates, known to be exclusively generated
by inflammatory  stasis;
   (c.) Analogy of textural destruction with that due  to inflammatory
exudation, more especially if coupled with analogy  between the exudate
 and a product  pertaining exclusively to inflammation, as between tuber-
 culous infiltration of the lung and hepatization, and  again between  the
 hepatizing tubercle and the fibrino-croupous exudate.
   Lastly,  it is important to decide whether the  appearances, in  the 
COROLLARY.
133
neighborhood of a  product, are residue of the inflammation that called
it forth, or the rudiments of a new consecutive inflammation caused by
the said product.   The discrimination, so far as it is feasible at all, may
be deduced from what has been already stated.

                             COROLLARY.

   (1.) The inflammatory process is especially fitted  for displaying the
primitive differences of blastemata, those inherent properties contingent
upon internal (endogenous) formative processes.
   (2.) It is equally adapted to demonstrate the commonly mixed charac-
ter of blastemata, and the consequent variety of elementary constituents
which enter into the composition of a new growth.
   (3.) It is the last of a series  of exudative processes, beginning with
the exudation of plasma in  the  act  of nutrition, which  in degree  and
kind probably all bear more or less resemblance to it.
   (4.) Scarcely a new growth exists, the blastema of which may not be
produced  by inflammation.   On the  other  hand, inflammation  yields
products proper to itself alone.  It is to be observed, at the same time,
that where  a corresponding crasis prevails, the stasis  requisite for the
formation of the product is  in the inverse ratio of the intensity of the
dyscrasial  process in the  general circulation.  Such  exudatory acts,
together with other processes to be discussed in the next chapter, are
wont, owing to the rapidity of the  effusion and to the slightness of the
accompanying stasis, to be characterized  as deposits.
   (5.) The homceoplastic textures produced by inflammation are areolar
tissue, a fibre analogous to that  of organic muscle, transition-cartilage,
bone, blood,  and bloodvessels.  The  regeneration of nerve-fibrils, after
wounds attended with loss  of substance, does not take place as a new
formation out of the exudate, but  as  growth of the  nerve from its cut
ends into the exudate, constituting a provisional cicatrix.
   (6.) Inflammation possesses now a  local, now a general import.   In
the latter case it is the localization of an anomalous crasis which stands
to it in the relation of cause.
   (7.) Inflammation may concur with a  crasis either accidentally or as
its symptom.  This has been to a certain extent  recognized by the
acceptation  of an arthritic, a  scrofulous,  a  scorbutic inflammation.
Custom has stamped inflammation with fibrinous exudates and a kindred
phlogistic crasis, as genuine inflammation.
   (8.) How ought we  to estimate that view which designates inflamma-
tion  as augmented, vital, and formative  energy—as  increased vascular
activity,—as reaction ?
   Neither  in the  sense of a neuro-pathological nor of an attraction-
theory, can  there  be any question of increased vascular  activity.  A
vigorous formative  power no doubt is  at  work in the inflammatory pro-
cess ; still, in the  formative efforts, the qualitative anomaly is predomi-
nant.  Even adhesive inflammation, in  which one might be most of all
disposed to look for an augmentation of the normal process of nutrition,
produces but few, and these simple, textures.
   To define  inflammation as a reaction of the organism against a mor- 
134
DEPOSITS — METASTASIS.
bific influence, is simply begging the question.  Inflammation is a morbid
process, unconscious of its scope or object, evoked by a causal impulse,
and  sustained or repeated so long as this impulse remains in activity.
Only in this general sense  of cause and effect  is  the definition of re-
action admissible.

                 DEPOSITS.—METASTASIS (SO-CALLED).

   Together with those inflammations leading rapidly and insensibly to
exudation, the  term deposit (metastasis, capillary  phlebitis, lobular
process) applies  aptly to certain processes which, considering the rapi-
dity with which they become established, are,  in  many respects, of  a
very remarkable kind.   These processes  are founded  in a sickening of
the fibrin, with  a tendency to coagulation.  They consist in the blood,
through  spontaneous impairment  or through  infection  [that is,  the
reception  of various substances], acquiring the tendency to coagulate,
and  actually coagulating within the circulating system, under  a more or
less marked separation of fibrin.
   This happens either in one of the  larger vessels,  or, what is far more
common, in the  capillaries of an organ.   In the  former case it is, con-
sistently with the frequent reception of  deleterious  substances into  the
venous  blood, the larger veins, usually in the vicinity of the  point of
infection.   With  respect  to the   capillary  system, no  point of it is
exempt, although the more  vascular organs, those  in which  the  blood
undergoes important changes, are  most obnoxious to the affection;  for
example, the lungs, the spleen, the kidneys.
   In large vessels it is not  difficult  to  interpret the appearances.  In
the absence of all  evidence  of local  inflammation of the  vessel's coats,
the calibre is plugged with lengthy, cylindrical,  or smaller, clod-like—
in vascular trunks membranaceous,—in arteries, especially where  the
inner surface is rough or gibbous,  adherent—coagula.  The probability
of these coagula resulting from inflammation of the vessels, increases in
proportion as the fibrin which constitutes them is pure, and as  its yellow
color and general  attributes approximate to those of croupous fibrin.
The various coagula found within the heart's cavities—the valvular, the
globular,  vegetations, belong to the same class.
   The cylindrical and  clod-like coagula are often equably reddened by
incorporated blood-corpuscles.   At other times they contain layers of  a
lighter color  than the rest, and which therefore have incorporated fewer
blood-corpuscles.  Some layers  are even  marked by a total absence of
redness, and obviously consist of pure effused fibrin.
   To trace the process in the  capillaries is not an easy  matter.  It is
conceivable that besides what happens within the vessels, and as a con-
sequence  thereof,  exudation of blood-serum, and even of a  portion of
plasma with  blood-pigment takes  place.  By means of this exudation,
the vessels become obscured and uncognizable.   Still, the  simple fact of
the process occurring in large vessels should remove all doubt as to its
existence  in the capillaries.
   In the capillaries of an organ, the process originally manifests itself 
DEPOSITS — METASTASIS.
135
by a dark red,  sometimes reddish-white, spangled  or  striated, circum-
scribed, impacted substance,  of  a dense, fragile consistence.
  These impactions possess the peculiarity of being seated for the most
part in  the periphery  of  organs,—the  lungs, spleen,  kidneys, for
instance.   They represent roundish tubercula or else wedges with their
broad  base directed towards the  periphery and  impinging upon the
sheath,—their  points  towards  the interior of  the organ.   They are
always present  in  considerable  number, and commonly associated with
exudative  processes.  Their size  is  mostly inconsiderable,  commonly
ranging  from that of  a  pea to that of a walnut.   In organs of a lobu-
lated structure,  they are sometimes called lobular metastases.
  The ulterior  changes are  various,  corresponding with  the nature of
the coagulation, and therefore of the blood-(fibrin) disease.
  They sometimes  shrivel  and condense, with obliteration of  the canals
of the vessels,  and of the implicated textures, into a fibroid  state,—
still further shrivelling  callus, towards which the neighboring parts are
retracted in a scar-like manner, and which often involves a  residue of
blood-pigment in the shape of rusty brown, or rusty yellow coloration.
   It is probable that, like the  thrombus, they are often  progressively
redissolved, and again taken up into  the circulation without detriment
to the textures.
   Sometimes they break  down to  a puriform, ichorous fluid,  to gangre-
nous ichor, with diffluence and  necrosis of the involved textures,  result-
ing in a pus or ichor depot, or a gangrenous slough.  In greater coagula,
this metamorphosis very commonly emanates from the central  layer.
Capillary  impactions, at the periphery of an organ, often assume the
aspect of a superficial boil.
  The coagula often undergo fatty conversion.
  Occasionally, the coagula have the character of tubercle or of cancer,
especially of medullary cancer ; and it is probably through this process
that the often very rapid development of cancer is produced in brutes,
by the injection of  cancer-blastema.
  In conclusion, many an important  crase-exhausting metastasis may
have its source in the same processes, involving a great extent of capil-
laries,  and issuing in gangrene.   Such metastases occur as the sequel to
typhus, and to the  exanthemata.
  With respect to  the organs whose capillaries are especially obnoxious
to these coagula resulting from  infection of  the blood,  as it is in venous
blood that  the  mischief commonly originates, and as the lungs are the
first organs  reached by the  poison,  their capillary tissue is commonly
the first to suffer.   In its arterial passage, the contaminated  blood next
attacks the capillaries of the spleen, and of the kidneys.  Lastly, in a
higher grade of the  dyscrasis, all the other textures, mucous mem-
branes, common integuments,  and subcutaneous areolar tissue, even
bone, become implicated in their turn.
  In infection of the  portal  blood, the liver is the first assailed, other-
wise it is only so in common  with other organs, and by no means more
frequently than the spleen and kidneys.
  That,  compared  with  the  greater vessels, and especially the arteries,
these processes  occur pre-eminently in the capillary system,  seems due 
136
ORGANIZED NEW  GROWTHS.
to the slackening of the  circulation  in  the  capillaries, which in itself
promotes coagulation,  and  at  the same time,  leaves the  deleterious
matter longer in contact with the blood.   In  certain  organs,  moreover,
their formation appears, as before stated, to be favored by the revulsion
which the  blood undergoes in them during the acts of nutrition and
secretion.
   Sensitive as  is arterial blood in respect to infection, as in arteries, for
instance,  coagula are  comparatively rare  in  arteries  of  the aortal
system, with the exception  of  those at  the point of arterial inflam-
mation.  This  is probably owing  to  the  great rapidity of the  arterial
current.   In the arterial section of the heart, however, they are readily
engendered by diminished action  of their organ, far more readily than
out of the venous blood in its right chambers.
   The relation which  these processes  bear to inflammation and its
terminations, is  obvious.   Determined  by  high grades of  dyscrasial
impairment of  the blood, they represent product formation, endogenous
exudation, within the vascular system.


         B.  ORGANIZED NEW GROWTHS SPECIALLY CONSIDERED.

   Having  now treated of organized new growths  in general, of their
blastemata, and of the several processes through which these are engen-
dered, we come to the special consideration of new growths.
   What order ought we to observe in this discussion ?
   (1.) An arrangement  based upon morphological relations is inadmis-
sible :
   (a.) The  elements being in themselves far too uniform, in their secon-
dary  arrangement too multiform, and generally too little distinctive of
the nature of the new growth.
   (b.) The  elements  being mutable, what is  one day in the embryonic
state, is found  further advanced on the morrow ; whilst various grades
of development are found to co-exist in juxtaposition.
   (2.) _ Similar  objections obtain  against  a division of  new growths
according to their main organico-chemical constituents; these being not
alone convertible substances, but also liable to enter into various combi-
nations in the same growth.
   (3.) With respect to the distinction of new  growths  into homoeoplasiae
and heteroplasiae, we have already once  expressed  an opinion.  A sys-
tematic arrangement upon such a basis, irrespectively of its preternatural
rigor, is open to the objection, that it breaks  up  new  growths into  two
great series, in the first of which no doubt many  points offer in the ana-
logies  for further subdivision.  In the second, however, we are  either
driven to a  ground of distinction alien to the system,  er else compelled,
in opposition to the principle itself, still to have recourse to comparison
with normal textures.
   (4.) How little the benign or  malignant nature of new growths in
general, affords a basis for a genuine classification is self-evident.
   In  order to avoid the difficulties alluded to,  we  shall here endeavor to
observe a middle path, and treat  of  new growths in a series beginning 
AREOLAR  TISSUE FORMATIONS.
137
with those which bear the evident tokens  of benignancy, and whose
ulterior development is  for the most part one of progress  into fibre;
passing next to those differently constituted in these particulars.


                  1.  AREOLAR TISSUE  FORMATIONS.

   The  new  growth  of  areolar tissue is a very  widely extended one.
Newly  generated areolar tissue occurs  both pure, and  also as a con-
stituent of other new formations, for  which  it often furnishes a  sort
of stroma or  framework.   Generally speaking, it is not alone as to the
constitution of, but also as to the arrangement of its fibres in new growths,
a repetition of the normal.   In the said stroma or  framework, however,
of many  cancerous growths,  there occur fibrils of extraordinary deli-
cacy.
   Its development often follows the  laws of  the  cell-theory,  that  is
nucleus, cell-formation, spindle-shaped, caudate cell, fibre with attached
nucleus, fusion of  several  cells to a varicose fibre, breaking up of the
fibres into fibrils.   Areolar tissue is, however, much more frequently and
more extensively shaped  out of the immediate dissilience  of  a solid
blastema into areolar tissue fibre, or else mediately, through  a prelimi-
nary splitting into  other coarser fibres.
   Newly  formed areolar tissue is often  found blended in different pro-
portions with elastic fibres, nucleus fibres in various degrees of develop-
ment, from the oblong, caudate nucleus, the rodlike fibre stem, to the
complete fibre.                                ,
   Apart  from its occurrence  as mere increment of that previously ex-
isting (hypertrophy)—areolar tissue of new formation is met with:
   (a.)  In the shape of threaden,  cord-like growths, of  flocculent  and
velvety accumulations,  of either free,  bridle-like, or agglutinated  and
firmly seated layers and  membranes upon serous tunics, even  of entirely
new-formed, movable, serous sacs.  In  many such cases it is, as mem-
brane, invested with an epithelium on its inner free surface.
   It determines  those frequent adhesions of organs contained within
serous sacs, both  with each other, and w7ith the parietes of the latter.
   (b.) It constitutes the entire parietes of perfectly new anomalous serous
and synovial sacs, or else it partially enters into their composition for
the most part as the external layer, in connection with fibroid textures.
To this  class  belong the anomalous bursae mucosae, the articular capsules
of preternatural joints, the capsules investing foreign bodies or extrava-
sate  (the envelopes of apoplectic cysts), every variety of cyst-formation.
   (e.) It forms the external vascular sheath of many new growths, both
benign and malignant, fibroid  and cancerous, or their stroma, for example
in lipoma.
   (d.)  Of tumors it forms the condyloma, the hypertrophous  lupus, the
pedunculated wart.   Commonly conjoined with fatty  texture, it  com-
poses those appendices of the  skin  denominated  mollusca, a species  of
so-called fibrous tumors and of fibrous polypi.
   (e.) Finally it presents in various grades of development an essential
constituent of scar-texture. 
138
FIBROID  TEXTURE.
  The growths composed of it contain a large proportion of gluten.
  The blastema for the new growth of areolar tissue is sometimes  fluid,
and the development takes place according  to the  call-theory laws, but
more often, especially when copious, it is solid and  fibrinous.   It exudes
during the progress of protracted hyperaemiae, and  in the last-mentioned
form, more especially,  as a consequence of inflammatory stasis.   Both
modes of development concur with suppuration.  Moreover, extravasated
fibrin,  as also endogenous fibrin-coagula within the  vessels furnish, under
certain conditions of the fibrin, the blastema for the  new  formation of
areolar tissue.
  The chemical changes which take place during this process of develop-
ment are very remarkable.  They consist in numerous modifications of
quantitative type, as also in qualitative differences of reaction observable
in the  gluten-extracts.
  The time requisite for the new growth of  areolar  tissue varies from one
to several weeks.   The process of dissilience into areolar tissue fibres
and fibrils, more especially in the case of copious solid  blastemata, is
often a very slow one.

                        2. FIBROID  TEXTURE.'

  In an extended sense, the collective term fibroid texture may be made
to comprise all fibrous  tissues, the development of which has been already
delineated, and the occurrence of which  as a more or less essential com-
ponent of various new  growths, it becomes our business to discuss.
  Nowhere is the insufficiency of a mere anatomical principle  more felt
than here—a principle which would needs occasion us to class side by
side, the most heterogeneous new growths, for example,  fibro-carcinoma
and the perfectly benign fibroid tumor.
  In a more restricted sense we comprehend under fibroid textures those
which  consist either of the  elements about to be described or of a blastema
manifestly furnishing their groundwork,  which yield gluten, are benign,
and in external appearance, resemble the fibrous texture.  In this  sense
the fibroid texture  enters into the  composition of  various  heterologous
growths, constituting in them  the  benign ingredient which cornifies or
ossifies by a spontaneous metamorphosis.  Or it is  woven in with normal
textures, or, lastly, it represents sharply defined, often very voluminous
masses, in a word, tumors.  The fibroid  (fibrous) tumor, besides the
aforesaid  attributes, is distinguished  as consisting entirely or almost
entirely of the elements of the fibroid texture.   It  is firm and elastic, or
else tough, presenting  a mere  local evil, independent of  dyscrasial taint
and originating in local deposition, a fact denoted more especially by its
selection of a particular organ, even where it occurs in great numbers.
  The groundwork of fibroid new growths are firm, probably always
fibrinous  blastemata.  Exudation  or  extravasation-fibrin,  or fibrinous
coagula within bloodvessels often constitute  these.
  Irrespectively of perfected areolar-tissue  fibre, as the main, if not the
sole constituent of  growths called, from their dense  texture  and their
resistance, fibro-areolar textures, or fibrous tumors,—the following ele-
ments  are in particular deserving of notice. 
FIBROID  TEXTURE.
139
   (a.) Flat, smooth fibres resembling the organic muscle-fibre, here and
there breaking up  into  fibrils, and thus engaged in the transition to
areolar tissue.   The nuclei  present  deport  themselves as upon muscle-
fibre, and the textures proper to it.
   (b.) Flat, broad,  band-like  or  roundish, shapeless,  solid fibres,  with
rough, denticulatad  or felt-like  outline, which are held  together by  a
solid blastema, and here  and there break up into areolar-tissue fibrils.
Nuclei often seem to stand in no developmental relation to them, and are
frequently altogether absent.
   (c.) The  fibroid blastema, an  embryonic, stratiform, fibro-laminated,
solid, transparent, or opaque (brawn-like), formation, interspersed, or not
interspersed, with elementary granules,  nuclei, and cells.
   The delicate fibre network of solidified fibrin is occasionally preserved
in it.
   The above-named fibre-elements originate directly out of their blastema
through dissilience.   The formations consisting of them occur both as
superficial expansions, and interwoven in normal  textures, as knotted,
spherical, or irregularly ramified masses (callosities); and, lastly, as inde-
pendent tumors.
   These various formations demand a special inquiry.  Besides the  true
fibrous tumors, of which we  shall  have to treat specially, we have  here
to mention:
   Inflammatory products, fibroid exudates, representing within paren-
chymata, irregularly knotted, ramified masses, or, upon serous mem-
branes, superficial expansions. The latter constitute pseudo-membranous
calli of various dimensions, but frequently engrossing  the entire super-
ficies of a serous sac.  They  are of various thickness, which is considera-
ble upon the parietal layer of serous sacs, of density and resistance equal
to those of fibro-cartilage; in color white, or as a consequence of hemor-
rhagic exudation, varied with black, slate-gray, rust-brown, or a yeast-
yellow.  They often  determine  complete conglutination of the parietal
and visceral layers of serous sacs.  Or, again, they are smooth and even,
or fenestrated, granular, stellate plates; or finally, they consist of granu-
lations, scarcely surpassing in size,  poppy, millet, and hemp  seeds, for
example, upon the cerebral arachnoid membrane, upon the hepatic and
splenic peritoneum, &c.
   The fibroid thickening of serous membranes in the shape of smooth or
granulated plates, of granulations, to which last are to be reckoned the
Pacchionian glands.
   Most free bodies found within serous  and synovial sacs.
   Cicatrix-substance generally, as also the so-termed keloid of Alibert—
arrested (ligamentous) callus.
   The internal layers of numerous cysts and of receptacles and excretory
ducts degenerated into dropsical  capsules (dropsy  of  the gall-bladder;
of the Fallopian tube).
   Callosed extravasate-fibrin, in shape of central or peripheral (encyst-
ing) membrane separated out of extravasates.
   Callosed coagulations of fibrin within the vascular system, the different
so-called vegetations  in  the heart's cavities, the cylindrical coagula
within veins and arteries. 
140
FIBROID  TEXTURE.
  The superimposed layers upon the internal  surface of arteries;  the
soft groundwork of so-called phlebolites ; &c.
  These fibroid formations not unfrequently inclose within a nidus, a
curd-like or puriform fibrin—the product of inflammation.
  The secondary arrangement of the elements above treated of, is redu-
cible to the following types:
  1. Parallel fibrillation, superficial expansion predominating.
  2. Fibre-felt, a multicrucial fibrillation, a section of which, in what-
ever direction made, always displays fibre-shoots and bundles, intersect-
ing each other  at various angles.
  3. Areolar disposition, of very rare occurrence, at least in pure fibroid
formations springing from a solid blastema.
  The two following structures, determined by a primitive disposition of
the coagulating process, are also rare.
  4. A network of fibroid bridles (fibre bundles), of from g^th to y'gth
of a millimetre broad, crossing each other at various angles, and having
their gaps filled up with embryonic elements—for the most part nucleus-
formations in an amorphous blastema.
  5. A web of similar fibroid cords  emanating from a central mass, and
anastomosing with other webs derived from other centres.
  These structures seem to occur more especially in fibroid formations
springing from extravasate-fibrin, as occasionally met  with in stratified
deposits upon the inner surface of arteries.
  6. Finally, a kindred  form is brought  about by resorption, as a gap
or fenestrate-formation,  the gaps being  round  or oval.  It occurs  in
fibroid tumors, in the fibroid thrombus, in  the  vegetations within  the
heart's cavities, but especially in the accumulated layers upon  the in-
ternal arterial membrane.   It is analogous with the fenestrated structure
of the striated coat of bloodvessels.
  All these formations have, even  for the naked  eye, the  aspect of a
porous, cancellated structure; the  gaps are, however,  widely different
from the alveoli of areolar textures.
  (d.)  A further  element of fibroid formations  is a cylindrical, in  its
parietes  structureless, striated  fibre,  with a simple, but  sometimes  a
double contour, inclosing granules, nuclei  and cells.   We have encoun-
tered this sort of fibre in consolidated  hemorrhagic effusion;  in  old
vegetations about the heart's valves  ; in fibred cartilaginous investments
of the joints; in the villous  new growths upon synovial capsules.
  (e.)  Another element, again, of fibroid growths is the nucleus and the
nucleus-fibre in the intermediate stages, as caudate nucleus, and varicose
nucleus-fibre.   These elements are to a certain extent found in conjunc-
tion with those hitherto discussed, with the concurrence, however, of an
amorphous bond-substance—a membranous basement.   They extensively
furnish forth fibroid growths, but are not very common.
  (/.) To conclude, not a few fibroid new growths consist in a fibre-felt,
developed within a basement either solid or adapted for membranous ex-
pansion.  It resembles that in the  intercellular substance  of  reticular
cartilage.  This  texture is  often met with in the fibroid deposits within
■arteries.
  A metamorphosis common  to  fibroid textures, is a so-called  ossifica- 
FIBROID  TEXTURE.                   141
tion,  and a cornification.   The  former is observed more especially in
fibroid tumors, in fibroid exudates, upon serous membranes, in fibrinous
coagula within the calibre of bloodvessels, in the deposits upon the inner
membrane of arteries, and the like.  The growth  shrivels with oblitera-
tion of its vessels, loses its  elasticity,  becomes dry, of a dingy yellow
color, and gradually bereft  of its fibrous texture.   Meanwhile a black,
minute  molecule,  consisting of  fat  with the salts  of  lime, becomes
imbedded in its substance.
   Cornification is observed especially in the vegetations about the heart's
valves, and in the layers accumulated  within arteries.   The  growth be-
comes dry, denser, of horn-like toughness, and  of dull transparency.
   Vascularized fibroid  growths occasionally take  on  inflammation, for
the most part  from the  surrounding  tissues, suppurate, and perish layer
by layer.   Nor is  it rare for them to  become  loosened and  cast away
through the suppuration of adjoining textures.
   Gluten yielding fibroid  tumor, also denominated fibrous  tumor, for-
merly designated as  sarcoma, steatoma, or even as scirrhus.
   They  are distinguished  from  other fibroid  tumors  by their indepen-
dence and circumscription, as being  sheathed in a layer of vascular and
areolar tissue, and thus, as  it were, impacted in the texture  of organs,
from  whence they may be  fairly peeled out.   They represent  more or
less perfectly  spherical, for the most part tough, fibro-cartilage-like, re-
sisting, distinctly fibrous, according to their degree of vascularity, whitish
or reddish-white, new growths.   In size they vary from that  of  a tumor
just cognizable, up to, and  beyond that of a  man's head.   They often
coexist numerously in the same organ.
   They  probably occur in every organ, although they are,  without
doubt, frequently confounded, more especially in  glands, with fibrous
sarcoma, and  with fibro-carcinoma.   They  are frequent in  the submu-
cous areolar tissue  layers, more  particularly in the intestine, stomach,
and oesophagus, now and then in  the larynx, again, in the subcutaneous
areolar tissue, and very commonly in the uterus  and its appendages,
where their development is  in every way very  strongly marked.   Their
texture is usually made up of areolar-tissue fibre, or of the elements de-
scribed at a, b, and  c.  The uterus fibroids, in  particular,  very often
repeat the fibre of organic-muscle tissue.
   With respect to the arrangement  of the  constituting fibres, fibre-
layers and fasciculi, much variety is manifested, and this, again, is pre-
eminently marked in the uterus fibroid.  Thus:
   (a.) The fibroid tumor, with concentrical lamination of the fibre-layers,
is commonly quite spherical, very dense and tough, poor in bloodvessels,
white, never attaining the magnitude of the species that follow.
   (b.) Fibroid, with manifold decussation of  the fibres.  The fibration
frequently springs  from distinct centres marked by their density and
whiteness.  These tumors  grow to a considerable  magnitude, and have
an irregular flattened tuberosity of surface.
   The following is a variety of this fibroid:
   The tumor  consists of an aggregation of dense fibroid tubercula or
centres,  about the size of peas  or  beans, united by means of a lax
vascular texture.   These tumors have an uneven undulating surface, and 
142
ELASTIC  TISSUE.
 attain to a very considerable bulk.  The loose interstitial texture some-
 times  becomes the seat of a serous infiltration, which, under dragging
 and eventual  laceration of the  said texture, may become^ exalted  into
 dropsy within the  tumor.  The fibroid contains within its interior a
 cavity replete with serous fluid,  fluctuates, and may thus present the ap-
 pearances of a cyst—in the uterus, more  particularly that of a hydro-
 metra.
   All these fibroids ossify.
   (c.)  There is one other variety of fibre-tumor,  which, so far as its ele-
 ments are concerned, ranks with the  foregoing growths. ^  In other
 respects, however, it  differs from them, and offers a transition  form to
 fibro-sarcoma.
   The characteristic of this last form of fibrous  tumors is that, varying
 in circumference, they are  so rooted in the implicated organs as not to
 be  removable from, without injury to, the latter; that they  become
 lobulated in their growth, and yield  little gluten;  whilst, on the other
 hand, they contain albumen, and in their fibrillation are, at least in part,
 developed out of cells.   Not rarely we find in them excavations lined
 with a smooth membrane, and filled with a sero-albuminous fluid, alveoli,
 cysts.   They  are further marked by considerable vascularity.
   Like other  kindred forms referable to the class of fibro-sarcoma, they
 are often  rooted in the submucous, areolar, and muscular  textures, in
 areolar tissue, in the periosteum subjacent to mucous membranes, and in
 the inner layers of the substance of the womb.  Here, under the designation
 of fibrous, sarcomatous flesh-polypi, they grow into the muco-membranous
 cavities, with  predominant longitudinal direction of their fibres, pushing
 forward the mucous membranes themselves in their advance, and repre-
 senting cylindrical, spindle-like, pear-shaped, bulbous tumors, lobulated
 at their free extremity, and traversed, more  especially in the uterus, by
 capacious bloodvessels (veins).
   As   so-called  polypi,  they are to be  carefully distinguished from
 mucous, cellular, or vesicular polypi.
   They do not ossify.

 3. ELASTIC TISSUE  AND  TEXTURE OF THE ANNULO-FIBROUS MEMBRANE
                            OF ARTERIES.

   The elastic and nucleus-fibres  enter, more  or  less, and  sometimes in
 very considerable quantity, into the composition of the most varied new
 growths, although in no instance  are  the latter entirely composed of
 them.
   We have,  however,  occasionally observed  accumulations of  elastic
 fibres, in the arrangement and form proper to the vocal chords, beneath
 the mucous membrane of the trachea, and close to the larynx.
   With reference to the texture  of  the  annulo-fibrous membrane, we
 have, in one instance, seen  the muscular fibres of a hypertrophied soli-
 dified, rigid, muscular tunic of the urinary bladder converted into dingy
jellow, elastic bands, which presented a texture exactly like that of the
 annulo-fibrous membrane of arteries.   A transformation of one texture-
 species, pertaining to a common genus, into another. 
CARTILAGINOUS  GROWTHS.
143
                     4.  CARTILAGINOUS GROWTHS.

  Wounds of cartilage are not reunited by means of cartilaginous sub-
stance, nor is this substance regenerated when destroyed.  Nevertheless
new growths of cartilage-texture are  both frequent and  voluminous.
The structure of these growths or tumors was first ascertained, with the
aid of the microscope, by Johannes  Muller, who applied to  them the
term enchondroma.   These excepted, not a single new growth, whether
designated as cartilage-like, fibro-cartilage-like, or as  cartilaginescence,
chondroid, fibro-chondroid, has more than a seeming analogy with true
cartilage texture.
  Enchondroma repeats all the special physiological  textures of carti-
lage.  It occurs both as  hyaline, genuine, as fibro-cartilage, and as
reticular cartilage, imitating  the  articular investments,  the laryngeal
cartilages, and  the septum narium on the one side, and the synchondroses
of the vertebrae, the cartilages of the external ear, the epiglottis, &c, on
the other.
   Ordinarily, and especially in the enchondroma of soft parts, all these
forms are often found in juxtaposition.  The  pure hyaline cartilage is,
however, the least common, the intercellular substance displaying, for
the most part,  a fibrillation similar to that in the cartilages  of the ribs.
   The enchondroma  forms spherical,  or nearly  spherical tumors,  with
an even, smooth,  or  else,  which is more usual, a mammillated surface.
Internally it either presents  a continuous hyaline  mass, or else, corre-
sponding with  its mammillated exterior, a lobulated structure, an aggre-
gate of denser, hyaline knobs  or spheres, either held together by a black-
contoured, rough, inelastic fibre texture,  resembling the  intercellular
fibrillation, or else imbedded in a loose texture imitating the fibre-layer
of reticular cartilage.
  Enchondroma chiefly occurs in bones, especially  in  the phalanges of
the fingers and toes, in the sternum, in the  ribs, more rarely in other
bones,  such as the long cylindrical bones, the ilium, the skull-bones.   It
is also  met with in the mammary gland, in the  parotis,  in  the testicle.
We  have  ourselves seen it in the subcutaneous areolar tissue, and  on
several occasions in the lungs.
  In magnitude, enchondroma  varies  from that of a tumor  only just
cognizable to that of a child's  head, and beyond it.   In bone, enchon-
droma exhibits two varieties, namely, enchondroma with and enchondroma
without bony sheath.   This osseous capsule is bone, whose texture  has
become distended and inflated by the enchondroma in the progress of its
upward development.  In this process it has, for the most part, increased
in substance, so that the capsule far exceeds, in this respect, the original
bone.  Where the sheath ruptures at an early period,  the enchondroma
is devoid of bony investment.   The capsular case of the enchondroma
is unessential, and is common  to many other  heterologous  growths de-
veloped out of the depth of bone, and more especially out of a medullary
cavity.  Many of the so-termed cases of spina ventosa of older observers,
were probably of the nature of enchondroma.
  Enchondroma is benign,  provided it  does not enter  into  any specific,
infectious metamorphosis, and  only undergoes ichorous destruction from
irritation.  A  peculiar predisposition  to its  formation  does,  however, 
144
BONE-FORMATION.
exist, as shown by its occurring numerously in one individual (phalanges,
ribs, &c.)  It affects young persons more especially, although  we have
known  examples  of  enchondromata  first  becoming developed  at  an
advanced period of life.  Here, however,  they are usually concurrent
with  exostoses  and bulky osteophyte  forms.  Echondroma generally
imitates the permanent  cartilages;  with exceptions,  however,—for it
ossifies.
   Not only have we seen in all enchondromata incipient ossification, but
our  museum contains specimens, for the most part, if not thoroughly
ossified.
   Ossified enchondroma is sometimes a white,  extraordinarily  dense,
ivory-like, sometimes a  yellowish-white, likewise  very dense,  although
uncommonly brittle, bony substance,  deviating in various degrees and
various ways from the texture of normal  bone.  This difference of habit
corresponds  to  a different process  of ossification,  and  to  a  different
elementary texture.
   In the first place, we miss the laminated structure of true bone.  The
medullary canaliculi  are present,  the bone-corpuscles large, spherical,
irregularly grouped, wanting in radiations.
   In the next place, and this refers to the second form of bony substance
adverted to, the process of ossification  recedes  still further from the
normal.   It resembles rather  a process  of involution, a wearing out of
the cartilage, and,  like the texture itself, it has its analogies in ossifica-
tion of the larnyx, and above all, of the  cartilages of the ribs.  The
intercellular substance of the hyaline enchondroma becomes dull, granu-
lated, sallow, lardaceous, and fibred.  The cells are centrally transformed
into spherical bone-corpuscles without radii, or else  the entire large cell-
cavities  are simultaneously, if not previously, filled with bone-earth.
They are interspersed without order, the last mentioned  forming com-
prehensive spherical or oval masses, which, with transmitted light, appear
black, and have a diameter  of y5th  of  a  millimetre.   The  lamellated
structure is wanting.   Medullary canals are wanting, or rudiments only
of their structure  are seen in the scattered  grouping of the cartilage-
cells.
   Enchondroma commonly occurs in  a simple form.  We have, however,
encountered it in the shape of  little millet or  hempseed-sized tubercula,
interspersed through medullary carcinoma of the testicle, an occurrence
allied  to the frequent entering of true bone into the  composition of
cancers.

                         5. BONE-FORMATION.

   Bone-formation comprises various new growths, which, in their de-
veloped  stage, are  readily divided into  two   classes, according to the
analogy which their texture bears to that of normal  bone.   Still the line
of demarcation is not sharply drawn,  owing to the multiplicity of transi-
tion forms from the one to the  other.   The one category  comprises new
growths identical, or nearly  identical with, the other, a  series of new
growths  less or more widely discrepant from the texture of normal bone.
On a closer scrutiny, however, this series again separates into the osteoid, 
BONE-FORMATION.
145
and into the bony concretion, which latter manifests itelf, more especially
in fluid blastemata, as cretefaction.
   It is, indeed, worthy of preliminary remark, that not alone solid blas-
temata and perfected textures, but also fluid blastemata, afford the basis
of, and are liable to,  so-called ossification.
   The  process  which involves the  conversion  of the substances here
alluded to into bone,  is commonly termed ossification, and thus  brought
into kindred relation  with the bony conversion of cartilage.
   We have here to observe:
   1.  In the first place, amongst the pathological growths with which we
are here more especially concerned, are ossifications for the most part
not constructed upon a preformed  cartilaginous  base, whilst  many of
them  deviate from the course and the results of  the ossifying process of
bone-cartilage.  It will be seen that in these last referred to, there is an
absence of the vascularization proper to the cartilage in its transition to
bone,  an absence of that  lamellated  structure-development, with that
grouping of the cartilage-cells, and that resulting arrangement of the
bone-cells, which  both exhibit in common.  In isolated cases, as, for
instance, in the ossifying of enchondroma, it is not in  the intercellular
substance, but in the cartilage-cell, that the ossification first commences.
That  ossified enchondroma differs in essential points from the texture of
true bone, we have already seen.
   Where no preformed cartilage,  but rather a rude, firm,  sod-like, and
fibrous,  or a fluid blastema,  or,  again,  an anomalous, mostly fibroid
texture, constitutes the groundwork  of the ossification, the  result is  a
concretion more or less uniformly penetrated by bone-earths,  and pre-
senting scarcely any  analogy with the texture of bone.
   2.  The characters  of ossification differ according to certain differences
in the implicated textures; or, where the textures are identical, according
to certain peculiarities in the process itself.
   The ossification of  a cartilaginous base has frequently, although not
always, an import coequivalent  with  that of ossified bone-cartilage—in
other  words, the import of a progressive metamorphosis into  a complex
vascularized texture.   Genuine bone-texture, on the other hand, can, in
the present  state of our  knowledge, be traced to a cartilaginous base
alone, the pre-existence  of which, if not  obvious, must be taken for
granted.
   The ossification of other  textural bases, on the contrary, has, if we
take into account other collateral changes  which these  bases, and more
especially the fibroid textures, undergo,  the import of a retrogressive
metamorphosis,  of a decay, of  a destruction of the base.  With the dis-
play of lime-earths in the  shape of black  molecules, the  textures lose
their  color, their succulence, and their elasticity,  waste, shrivel,  toughen,
dry up, and become  more or less lardaceous.   Not  alone  do  no new
bloodvessels make their appearance, but old ones, if there  be any, be-
come  obliterated.  Fluid blastemata in the course of cretefaction become
turbid, chalky,  gritty to  the feel.   Under  the development of  fat, they
form into a pap, and  eventually thicken  down to a mortar-like concre-
ment.   Even in cartilaginous bases, ossification  is often so modified as
  VOL.  I.                           10 
146
BONE-FORM ATION.
to represent  rather  a retrogressive than  a progressive metamorphosis
(compare enchondroma).
   3.  A most important and  comprehensive question relative to  ossifica-
tion generally, and therefore to bone-cartilage inclusive, is:  whence are
the lime-earths which incrust  and penetrate the  various  soft  textural
bases derived ?
   A  narrow  scrutiny of  the ossifying  process,  especially  in fibroid
textures,  and of  the cretefaction in  soft  and fluid  blastemata, will
speedily convince us that the appearance of lime-earths is not essentially
due to their deposition out of either a pre-existent or a new-formed and
special system of bloodvessels within the ossifying growth.  For, when
we see growths ossify, -which are almost, if not entirely  devoid of blood-
vessels, and  which  are, at  the  same  time, remote from  the vascular
system of other formations (for instance, free bodies within serous sacs);
when we see the process of ossification often attended, not with any new
growth of bloodvessels, but with the obliteration of existing ones ; when,
again, we reflect upon the  concomitant  changes wrought in textures dur-
ing their  osseous conversion, their wasting and discoloration, the inter-
larding of their shrivelling substance with free fat,  we are fain to look
upon  the  entire process as the result of the total transformation of the
chemical constituents;  as, in fine, an  elimination of pre-existent lime-
earths out of their primitive  connections.
   Even in the normal ossifying of bone-cartilage, the process is the same
at the commencement, the  lime-earths appearing long before the develop-
ment  of any vascular system.  This,  then, offers at least one connecting
link for all processes of ossification.
   In  the revolutions effected by the ossifying process, a most important
part is without doubt assignable  to the accession  of  fat.   It is common
to all processes of ossification, and probably results both from a release
of pre-existing fat from its primitive combinations, and of a simultane-
ous conversion of protein substances into fat.
   From these preliminary remarks, we may at once proceed to a muster
of the new growths belonging to this  category, premising, however, that
much relating to them will have to be discussed more at large in later
chapters of the present work.
   1.  Uniform or almost uniform  with the normal bone,  are:
   (a.) Bone developed in permanent cartilages, and especially  in those
of the larynx,  sometimes  and in  part also the  ossifications of costal
cartilages.  In them, however, we usually miss the lamellated structure
of normal bone.
   (b.) Bone-structures which form as callus for the reunion of fractured,
and for the regeneration of lost bone, hyperostosis, whether  external or
internal (sclerosis), exostoses, and all osteophytes, including such as in
the shape of thorny, stellate, or  scaly bone-growths  and fabrics,  enter
into,  and sometimes  greatly  surpass  in volume, certain concurrent new
growths, especially such as occur in bone.
   Notwithstanding the all  but identical relations of the  texture of these
formations with that of normal bone, they present not a few  important
discrepancies, cognizable  both by a general  comparison  with normal 
BONE-FORMATION.
147
bones, and by a special  comparison  with  those directly  implicated.
Thus, as examples, we may adduce the inferior vascularization, inferior
number of medullary canals, less marked lamellated structure, anomalous
amount and irregular disposition of the  bone-corpuscles,  in  the new
bone-growths.
  As regards the process of ossification in the several blastemata, that
produced by inflammation is the best  adapted for investigation, as being
at once  the most frequent, and  the most  voluminous.   The flaky or
fibrous basis of the exudate  furnishes the  fundamental (intercellular)
substance of the cartilage.  Within  this cells become  developed, which,
following the process of physiological bone-formation,  change into bone-
corpuscles.
  (c.)  The slowly developed bone-nuclei in callus, arrested at the stage
of a ligamentous formation in bone-fractures, trephine-gaps, &c.
  (d.) Osseous growths developed beyond contact with bone on the dura
mater, as also upon the cerebral arachnoid,  and upon the free visceral
plate of the spinal arachnoid membrane; the so-called ossifications upon
the intermuscular ligaments in the vicinity of hyperostosed articulations,
and of the membrana obturatoria of the pelvic foramen ovale.   The ossi-
fications occurring in tendons  are said by  Henle to be of true bone-
texture, as are also, in fine, the bony concrements found impacted within
healthy muscular textures.
   2. Osteoid.—Several of the growths adverted to as deviating in cer-
tain points  from standard bone-texture, might be  transferred to this
section.   To it, however,  belong more  especially ossifications  of  costal
cartilages, and most of all ossifying enchondromata, both in bones, and
in soft parts.   In bone  there occur independent  texture-supplanting
tumors, which consist of an ivory-like, dense, white bone-substance, and
which are seen both in this, and in their general character to be ossified
enchondromata.
  Miiller's  osteoid is a bone-formation which enters redundantly into the
parenchyma of  cancer.  Its constitution is  identical  with that of true
bone, and it will be discussed under the head of Cancers.
  3.  Concretions.—Under certain, as yet unknown, conditions, the lime-
salts in a soft basis are, by dint of a revulsive  metamorphosis, set free
so as to incrust  and penetrate  the said basis,—in a word, effect its ossi-
fication.
  Such bases are the fibroid textures and blastemata occurring in the
form of independent tumors, t)f membranous expansions, or of irregular
masses lodged and entangled within various  parenchymata.  They may
be the product of inflammation (exudation), or merely of an anomalous
act of nutrition.  The blastema may moreover  be extravasate-fibrin, or
spontaneous fibrin-coagulate within the  vascular apparatus.   Such bases
are fibrous tumors, fibroid  hardened exudates upon normal and anoma-
lous serous membranes, within  parenchymata, in the  cutis as  scar-tex-
ture, on the heart's valves, in muscles, in the  heart's walls.   Such, again,
are the central and the peripherous fibrinous deposits in extravasates,
after entering upon a fibroid transformation, hypertrophous  thickenings
of serous membranes and of the tunicae albugineae.   Such are, in fine,
the Pacchionic bodies, the  different fibrin coagula in the heart's cavities 
148
BONE-FORMATION.
(so-called vegetations), the stratiform deposits within arteries, and the
soft matrix of the phlebolite in veins.  To sum up, therefore—all the so-
termed ossifications of serous membranes, of  the thyroid  gland, of the
heart's valves, of fleshy muscle, of arteries, and of veins.
  Even the fibroid fabric which enters into the composition of malignant
growths, for example of cancers in soft  parenchymata, now  and then
ossifies into a bony skeleton, or shell-like framework.  This is, however,
not to be confounded  with the thorn-like, stellate  and scaly  stroma of
true bone-texture, accompanying  numerous  heterologous growths as de-
veloped in and upon the bones.
  The ossification offers little or  no analogy with normal bone, and its
development.   The bone-earth enters in a molecular form, accumulating,
for the most part irregularly, in the soft basis, until the  latter is con-
verted into  compact bone.  The  bone-earth is  capable of being  with-
drawn by  acids, with  restoration of the soft basis.   It has  sometimes
acquired the  aspect of a stratiform  deposit.  Many a wide-spreading
ossification,—of the arteries for example,—is concurrent with excessive
fat-production in its vicinity.
  4.  Cretefaction.   Finally, fluid blastemata are also liable to ossifica-
tion.   The process is  perfectly identical with that which takes place in
the fibroid blastemata just enumerated.   It is in like manner conditional
upon a metamorphosis of the fluid blastema, by virtue of which, the in-
corporated  lime-earths being set free,  predominate.  Morphologically
speaking, the blastema displays the development  of free or of celled
molecules (granule-cells).   It is always  accompanied by fat in a mole-
cular  form,  and by cholesterine crystals.  The ossification  manifests
itself as a lardaceous  chalky pulp, as a cement-like and friable, ulti-
mately, as a compact calculus-like growth.
  The blastemata entering into this process are either  originally fluid,
or else originally solid, and subsequently liquefied (croupous fibrin).
  These blastemata are either exudates external to the vascular system,
or deposits internal to the latter, for instance, accumulated layers within
the arteries, the basis  of  vein-stones in the veins, or coagula  smaller or
greater in extent (vegetations).
  To this series belong the  cretefactions of fibrinous, albuminous exu-
dates, of pus, of tubercle, of atheroma in arteries,  of vegetations on the
heart's valves, of coagula in the veins.   Just like ossification, crete-
faction presents various grades from the aforesaid  progressive pulp-like
thickening, to the cement-like,  and  at  length the  compact, calculous
concretion.
  A very peculiar  kind of ossification  is represented in the cell-incrus-
tations, which have  their  physiological  analogues  in the pineal concre-
tions.  They appear in a  variety of shapes  in  the vascular plexuses,
especially in the  turbid,  chalky, speedily  condensing moisture  of the
cysts  of the  choroid  plexus,  as  also in sarcomata  and  cancers, more
especially within  the  brain.   The  cells  both as primary and as parent-
cells,  together with their  contents, fill  with lime-salts, now in  a mole-
cular shape, now in that of concentrical layers. 
GROWTH  OF  BLOODVESSELS.
149
                    6.  GROWTH OF  BLOODVESSELS.

  Setting  aside  all dilatations of the smaller vessels  and capillaries,
constituting the so-called aneurysma anastomoticum  and telangiectasis,
we shall here treat of all that concerns the new growth of bloodvessels.
  Upon a somewhat slender foundation of facts with which we have to
commence, we must endeavor to build up  a superstructure of well-consi-
dered hypothesis.
  1. The common occurrence of this new growth in inflammatory pro-
ducts is incontestable, more especially in the  adventitious membranes,
affecting serous tunics.   It is at the same time matter of certainty that
such new vessels by no means originate through any prolongation of
pre-existent vessels in the contiguous textures, but that the new process
of development is altogether  an  independent one, and that only at a
later epoch do the new-formed vessels enter into anastomosis with the
older ones.
  The process of the new growth of  bloodvessels in inflammatory pro-
ducts of this kind is as  follows:
  In the first place, blood is seen to occupy little vacant spaces within
the blastema or exudate thrown out in consequence of the inflammatory
stasis.  In other words, certain, for the most part irregularly spherical,
ramified, to the  naked eye point-like, areae, unlined with any  proper
membrane, fill with blood; areae obviously determined by the upspring-
ing  of  blood  out of the  blastema.    Both their remoteness from old
vessels, and their ulterior  development, controvert the idea of the con-
tained blood consisting of little extravasates.   This blood represents an
aggregate of blood-corpuscles which the concurring  testimony of Vogel
and  myself has  shown to be of various  magnitude, for  the most part
imperfectly round; not precisely disk-like, nor possessed of the intense
redness of  old  blood-corpuscles.   They are moreover soft, and  adhere
both to each other and to the parietes of the  containing  areae.   From
these areae  there are gradually developed in all directions, sometimes,
however, predominantly in  a single one,  blood-streamlets  contained
within  chinks or  canals in the blastema, and having no perceptible con-
fining membrane.   In minuteness of calibre, they excel the finest capil-
laries.   Their  next step  is to become  invested with  a structureless
confining membrane, the internal bloodvessel  membrane,  to which the
outer layers associate themselves by and by.   Finally  they  shoot out
from various centres to anastomose with one another,  and eventually
with the old textural vessels.
  In this process two material points remain unaccounted for, namely,
first, the primitive development of the  blood-corpuscles in those central
areae.   The question is—their spontaneous and independent origin out
of the common blastema being manifest, what portion  of the latter is
devoted to this purpose, and what chemical changes does the act involve ?
  Secondly: How do the  vessels originate ?  In  reference to the last
question it  may be asserted :
  (a.)  If we may judge  from past observations, the vessels in these blas-
temata do not spring from  primary blood-holding cells.   The absence
at first of any sharply defined contour in the said areae  disproves their 
150
GROWTH  OF  BLOODVESSELS.
being primitive cells, or the blood-streamlets  emanating from them,
prolongations of cells.   This leads us to the more  probable assumption
that:
  (b.) The blood forms out of the  blastema generally, and  where  the
latter has wrought itself into cells, not within these, but in intercellular
spaces between them.  Where, however,  blood and bloodvessel forma-
tion frequently precede  cell-development, and more especially where it
takes place in blastemata in which cell-development is either wanting
altogether, or plays only a very subordinate part (for example, in fibroid
blastemata), it  can  only be alleged  that  the formation takes  place in
chinks and  chamberlets worked out of the  blastema by the blood itself.
The structureless membrane  which  subsequently confines  the blood
streamlets, is in all likelihood a secondary endogenous  formation out of
the blood, the  remaining layers  being built  over it, so to speak, exter-
nally, out of the blastema.
  As regards the relation of new bloodvessel development to  the cha-
racter of  the blastema, the following points seem to present  themselves
for  further inquiry.
  (a.)  In different products of inflammation, there is virtually a very
different degree of proneness  to the new  growth  of bloodvessels.   In
some it is excessive, in  certain others, in the progress of development
into precisely  the  same texture  (the areolar), it  is very faint indeed.
Upon the parietal layer of the cerebral arachnoid, adventitious mem-
branes  occur, which  along with an  inconsiderable  amount of nuclei, of
nucleated cells, and  of areolar-tissue fibrils, consist mainly of blood-
vessels.
  (b.)  The new growth of bloodvessels is directly proportionate to  the
general  capacity  of  the  blastema  for  textural  change.  Blastemata
which  linger long in their primitive crude condition, and also which
serve for the groundwork of indistinct fibroid textures, exhibit little, if
any, new growth of bloodvessels.
  The new formed vessels give token of a delicacy of structure, and a
vulnerability in full accordance with  their recent  origin.  To  this  are
probably due the hemorrhagic products upon their becoming, when only
just formed, the seat of inflammatory stasis.   The  fact is, moreover, to
be  inferred from the new-formed vessels  originally consisting of  the
primitive  vessel-membrane alone ; and not until a later period  attaining
the perfected organization of old bloodvessels.  In new-formed vessels
of considerable calibre, we have  frequently missed the layer  of trans-
verse-oval nuclei.
  The  vascular apparatus  of  new  growth is marked by, for the most
part, long,  stretched vessels,  by  rare  dichotomous ramification, with
hardly perceptible decrease of  calibre, or by a wide-meshed disposition.
  A nervous system has not as yet been demonstrated in them.
  The  new bloodvessels both in the spurious membranes adverted to,
and also in other new growths, are, as experience has  again  and again
shown,  susceptible of inflammation, and this in very early  stages of their
development.   Here, for reasons both self-evident and already referred
to,  they are wont to yield essentially hemorrhagic products.
  The manner in which their anastomosis with old vessels, or with par- 
GROWTH  OF  BLOODVESSELS.
151
ticular arteries or veins is effected, has not been  thoroughly made out
by experiment.   As regards  the former case, it is probable that the
anastomosis is brought about by an act of resorption in the wall of the
old vessel, at the point where  the new vessel rests.
  With respect to the second point, Van der Kolk has distinctly shown
that in the case of  adhesions  of the lung to  the costal parietes, a con-
nection becomes established, on the  one side with the system of the
pulmonary artery, on the other side with the aortic circulation.   And
although this fact may not warrant all Van der Kolk's deductions, it is
nevertheless highly important, as offering a connecting link with  other
observations of his own upon anastomoses, to which we shall hereafter
have to revert.
  New-formed vessels  doubtless undergo obliteration  in spurious  mem-
branes, just in the same gradual manner as in the cicatrix, and probably
for the most part in the progress and  sequel  of the retrogression,—the
wasting—of the new textures themselves.
   2. As in inflammatory  products, so also in other blastemata, does a
new growth of  bloodvessels  occur.   An examination of these proves
incontestably  that  there is a second  mode  in which a new growth  of
bloodvessels may take place.  We  have  satisfied ourselves of the deve-
lopment of new vessels out of parent-cells in  cancerous structures, com-
posed, amongst other elements,  of spherical or acinus-shaped parent-
cells.  Numerous cyst-like cells,  with structureless parietes, contained
in place of the brood cells of  carcinoma, soft, adherent blood-corpuscles.
Many of  them  bulged  out  in all directions  into coecal  sacs, freighted
with the  same  contents, and entering into  anastomoses with  others.
Blastemata, therefore,  entering into  cell-development,  are in reality
capable of producing a new development of  bloodvessels out of cells.
   Certain new growths are remarkable for being rich, others for being,
in various degrees, poor in  bloodvessels.  The former  are  mostly loose
in  texture, and consequently  capable of  considerable  intumescence.
Their  hyperaemiae  are  for  obvious reasons,  readily  exaggerated into
hemorrhage,  and their inflammation  is  especially  liable to determine
hemorrhagic products.   Amongst the malignant new  growths,  medul-
lary cancer is notorious in  this respect.  Its highly developed vascular
apparatus is doubtless the  source of its excessive nutrition, of its  rapid
and often monstrous growth.  It is pronounced by  Van der Kolk  to be
of arterial nature, in other words, to anastomose with arteries only.
   Very vascular new growths form the transition-link to  nearly pure
bloodvessel-formation.  For blastemata are  not wanting which present
almost  exclusively the  groundwork  of  new bloodvessel-formation—in
other words,  of a new growth, consisting  almost  exclusively of new
bloodvessels.
   To this class belong the following new growths, concerning the deve-
lopment and import of which much obscurity  still prevails.
   (a.) Cavernous textures, cavernous  blood-tumors.—These growths are
of  a cancellated  structure, somewhat resembling that of the corpora ca-
vernosa.   They consist of areolar tissue fibres, constituting a multilocu-
lar stroma, the  interspaces of which  are invested with a structureless
membrane, and contain  blood.  Numerous caudate cells liberated during 
152
GROWTH  OF BLOODVESSELS.
the investigation appear to be the ddbris of an epithelium.   The  inter-
cellular spaces  communicate amongst each other ;  for, by pressure, the
tumor may be completely emptied through a cut surface.   They are sur-
rounded by a tolerably dense capsule of areolar tissue, along with which
they may be peeled out of the textures.  They always communicate with
a considerable vein, through which they will take  up an injecting mass.
No arterial  ramification is demonstrable  within  their  texture.   They
are very tumefiable, forming upon the surface of  the  body and at  the
periphery  of organs,  protuberant, compressible, but  resilient  dark-blue
tumors, which supplant the original textures.
   They are commonly  regarded  as  telangiectases,  and without doubt
they pass, with many practitioners, for  examples of fungus haematodes.
By the French (Andral), they  are termed  "spurious  spleens" (After-
milzen), " placenta-like textures."  In our opinion, they are by no means
dilatations of bloodvessels, but  to all intents and purposes new growths,
and, as far as our experience goes, altogether benign.  We  have never
seen them concurrent with a malignant growth.1
   Their mode of  development  is not clearly  made out.   Numerous ob-
servations,  however, render it  probable that they originate  as  blood-
vessel growths  in their  most extended sense, as  blood-bearing  depQts
and canals, formed by absorption out of a solid blastema.  Whether the
contained blood be a primitive endogenous new growth, or become intro-
duced into it subsequently, we know not.  Thus considered, they bear
a close  analogy with the fenestrate and canal formation in certain blas-
temata  pertaining  to the vascular system, in the superincumbent layers
upon  the inner membrane of arteries, in the fibrinous coagula within the
vascular system, in the thrombus, &c.
   Within the cancelli small concretions occasionally form,  corresponding
to the phlebolites of veins.
   We have seen these cavernous textures developed in the subcutaneous
areolar  tissue of the thigh, and communicating with the saphena vein, as
also in  the substance of  the lips.  We have seen them as tumors grow-
ing out of  the diplb'e of the  skull-bones, and penetrating the compact
outer skull-plate, and, again, in tke texture of the  pia mater.   They are
the most frequent  of all, and the most various in dimensions, up to, and
beyond those of a  duck's egg, in the liver, where they communicate with
branches of the portal vein.
   (b.) Fungus  hcematodes,  blood fungus.—What is  commonly held to
he fungus hcematodes, is a luxuriant vascular  growth, mischievous, both
from its liability to occasional hemorrhage, and from  its tendency to ex-

  1 The  author has since modified his opinions respecting these, so-called " cavernous tex-
tures." Abandoning the ground of their development out of a solid blastema through partial
resorption, he now regards their stroma as nearly identical with that of cancerous struc-
tures, both in its elementary constitution, and in the fact of the same dendritic excrescences
springing from its septa, and growing into its chamberlets. The affinity of these tumors to
cancer, the author considers further established by their not unfrequent concurrence in the
same organ (the liver, for instance) with cancerous tumors.
  Incipient cavernous tumors do not, it is asserted, present any anastomosis whatever with
the venous system. The anastomosis is established only at a later period through the me-
diation of very minute venous offshoots. It is not made clear, however, in what manner
this communication is brought about.  (See Rokitansky " iiber die Entwickelung der Krebs-
geruste."  Sitzungs-berichte der Kais. Akad. der Wissenschaften, Marz, 1852.)—Ed. 
GROWTH  OF  BLOODVESSELS.
153
haust the  constitution by the habitual hemorrhage consequent upon its
ulceration.   Some  deem  it  curable by  removal with  the  knife, whilst
others maintain that it invariably recurs either at the same spot or else-
where, and that it  is of cancerous nature.   Some  even fancy, that not
only does it return in its primitive form, but that it  may be replaced by
another form of cancer, namely, the medullary or encephaloid.
   Our own opinion respecting the occurrence of fungus haematodes, is to
this effect:
   1.  It is incontestable that  highly developed,  bleeding,  ulcerating
telangiectases, as also cavernous  textures, are frequently  mistaken for
fungus hcematodes.  This applies still more forcibly to a highly vascular,
bleeding, ulcerating, blood-turgid  medullary carcinoma.  Nay, we have
often seen a  tumor, diagnosed as fungus haematodes, resolve itself in the
dead subject, after  collapse of the bloodvessels had taken  place, into a
medullary carcinoma.
   2.  We are convinced of the existence of new growths almost wholly
made up of bloodvessels ; we even regard it as likely that the so-termed
telangiectases (both congenital and adventitious) are, for the most part,
new growths of bloodvessels.
   The question with respect  to such luxuriations of bloodvessels is, what
is it that determines  their (innocent or malignant) character ?  We be-
lieve  this to  reside, not in the bloodvessel  growth, but in the remaining,
namely, the  intervascular, portion of a common blastema ; just as in the
malignant osteoid, not the bone-luxuriation, but the adjacent, soft hetero-
logous parenchyma, determines its cancerous nature.  Scanty as is the
proportion of  this intervascular heterologous substance to the  blood-
vessel growth,  the former merits, in this  sense, the most  ample consi-
deration, and however important  bloodvessel luxuriation in itself may
be, the  term fungus haematodes designates  but a secondary feature of
the entire new growth, a modification, through accidental excess of vas-
cularity, of a new growth well-marked, only imperfectly examined. The
designation vascularized areolar tissue or  vascularized cancerous for-
mation, would be both more  philosophical and more practical.
   Hence the benign or malignant character of a new growth associated
with excessive vascularity would, in such cases, be primitive.
   Can the benign new growth of this  kind become malignant ?   It can
hardly be  doubted  that vascular  tumors may accidentally become the
nidus of a malignant new growth, just as may any natural organ rich in
bloodvessels.
   Another kind of consecutive  degradation to malignancy is  also con-
ceivable, although for the present little more than hypothetical.
   To explain our  meaning it will be  necessary to enter upon a little
further discussion.
   Bloodvessel luxuriations represent, when the anastomoses with the old
vessels are completed, a new  vascular apparatus complete within itself, a
repetition, so to speak, of the portal system.
   The anastomoses might be of  such a  character  as  to attach solely
either to the  arterial or to the venous system.  Van der Kolk  considers
this proved,  maintaining that medullary carcinoma  belongs exclusively 
154
FAT-TEXTURES.
to the arterial, and another new growth, which he denominates fungus
haematodes, to the venous system alone.
   A vascular apparatus of this kind not being conceivable without inter-
change of matter, it might be  not unreasonably inferred—
   1. That the products of such a process would differ according to the
arterial or to the  venous nature of the blood circulating in the tumor,
and that the products would be more especially anomalous where blood,
previously rendered venous, has to permeate a secondary system of capil-
laries.   In  both cases  the circulation must needs become  torpid, and
prone to undergo stases.
   2. That the  crasis of the  general circulation must suffer a change,
more especially in the second  case.
   In such wise, vascular luxuriations might indeed be imagined  to pass
into  malignant new growths,  the product, namely, of their interchange
of matter constituting a malignant blastema.
   The new formation of lymphatics has been demonstrated by Van der
Kolk in adventitious membranes and in cancers.

              7. FAT FORMATION, FATTY DEGENERATION.

   The anomalous occurrence of fat  is no  less frequent than multiform.
The  subject is daily acquiring fresh interest, in proportion as the im-
portance  of fat in the animal economy, from  the  incipient stage of
digestion through  every process of  assimilation, up  to the formation of
the elementary cell, renders itself more and more apparent.  It is, how-
ever, quite within the compass of pathological anatomy to testify that
protein substances, and in particular fibrin and albumen, are capable of
undergoing conversion into fat.

                           FAT-TEXTURES.

   1. Normal.—We have already adverted to the excessive formation of
fat generally, and to its accidental  unequable accumulation about certain
organs, amid general wasting  of this tissue, for example, in the omentum,
the kidneys, the mediastina, on the pericardium,  and  on the heart.   We
have here to advert more particularly to fat collections still more marked
by their locality and limitation.  Of this kind are—
   (a.)  Those collections of fat important in various ways, which encircle
diseased, and  especially calculous  kidneys, or  such as have  become
atrophied  through  Bright's disease, or   surrounding anomalous bone-
formations (offering some analogy with the medullary system  of bone),
as in ossifying arteries, in the vicinity of cancers, &c.
   (b.)  Lipoma or fatty tumor, an accumulation of adipose tissue in the
shape of a spherical, oval, lenticular, more or  less lobulated tumor, in-
vested with a delicate capsule of areolar  tissue, and permeated by equally
delicate and spare continuations of the latter.  Its size is from that of a
hemp-seed or a pea, to that of a man's head, or  more.
   It consists, as a mere repetition of the normal adipose  tissue, of  sphe-
rical fat-cells, wherein are discoverable stellate or radiating crystals of
margarine or margaric acid.  Where the areolar tissue capsule is  more 
FAT-TEXTURES.
155
strongly developed, the lipoma is an encysted one.   We have  met with
such encysted portions in the midst of loosely lobulated lipomata.
  The  lipoma occurs  chiefly in the  subcutaneous areolar tissue, more
especially  in  localities where  fat is deposited in  more  than ordinary
amount in  the healthy state, and where  accidental circumstances cause
its still further accumulation, as at the glutaei, at the thighs, at the back
and neck, about the shoulder.  It is, however, also observed in parts less
abounding  in fat, as beneath the  hairy scalp.   Again, it  occurs in the
submucous areolar tissue  of  the stomach, of the intestine, even of the
bronchia;  in the subserous areolar tissue of the parietal, as well as of
the visceral layer, although more commonly of the parietal, in serous and
synovial sacs;  for example, beneath  the  pleura and peritoneum, upon
the inner surface of the dura mater, and upon the investing membrane
of the ventricles.  It has been fully described as  it  occurs in synovial
sacs,  more especially of the knee-joint, in that peculiar form which Joh.
Miiller has denominated lipoma arborescens ; a form to which all lipoma-
tous accumulations beneath serous sacs incline.  We have also met with
lipomata in glandular organs, more especially in the lungs,  liver, and
kidneys, in bone affected with osteoporosis and eccentrical atrophy.
   Large lipomata in subcutaneous and in  submucous  areolar tissue,  by
dint of traction, acquire a pedicle, and lapse into the  cavity, it may be
of the intestine, in the semblance of a polypus.
   Lipomata occur, for the most part, solitarily.  Instances are not quite
rare, however, of several, or even many coexisting beneath the subcuta-
neous areolar tissue.   Such cases are the more remarkable,  that they
may affect individuals not otherwise at all prone to excessive fat forma-
tion.
   In itself lipoma is innocent.  By compression, traction, and hampering
of space, it may be rendered nocuous. Moreover, its general integument
may, through violent tension, through inflammation  and suppuration, or
through a sloughing process, occasion consecutive ulceration of the tumor,
and exhaustion of the powers of life.
   It is seldom traceable to palpable mechanical injury.  In the majority
of cases, more especially where several lipomata concur or succeed each
other in growth, there is evidence of neither blow nor compression.
   The term steatoma,  so often misapplied  of old, has  been reserved by
Johannes Miiller to designate a peculiar species of lipoma, in which the
fat texture is lobulated, as it were, through the intervention of  a permea-
ting membrane of areolar tissue,  the latter forming a  main constituent
of the new growth, and imparting to it greater toughness.
   2.  Abnormal (fat-texture).—To  this  category  belong, in the first
place, cases in which the contents of the fat-cells vary from the natural
character; in the second place,  cases in which the cells themselves deviate
from the normal type.
   (a.)  The fat-texture manifests, under certain conditions, anomalies for
the most part referable to the nature of the contained fat;
   (a.) The latter being sometimes preternaturally  diffluent, like  oil-fat
(oleine).   It is more than usually unctuous.   On pressure or  incision it
gushes forth abundantly, and in big drops.  In the dead subject,  neigh- 
156
FAT-TEXTURES.
boring parts are often  found infiltrated  with liquid  fat.  It is mostly
tinged of a deep yellow, and resembles marrow.
   These characteristics very commonly attach to the fat of the  old  and
cachectic, laboring under osteoporosis (from atrophy), extensive ossifica-
tion of the arteries, osteomalacia ;  and of younger individuals a prey to
cancer.  Similar properties belong in an especial manner to  fatty accu-
mulations usurping the place of muscle or of pancreas-texture.
   (P.)  The fat contained within the cells is  firmer, stearine-like, resem-
bles mutton suet, and dulls the blade of the scalpel.  The entire fat of
the individual is of this character, more especially  that of the  subcuta-
neous  adipose tissue, and  it  is commonly  associated with strongly de-
veloped pigment formation in the rete mucosum, and a copious secretion
from the sebaceous glands,—an oily  skin.   These properties mark, in
an especial degree, the fat  of younger dram-drinkers, and are almost
without exception concurrent with lardaceous affection of the liver.
   This variety may be caused by  the fat containing a larger proportion
of margarine; perhaps, also, by the  development  of stearine.   Spirit-
drinking has a very marked  tendency to produce it.
   (b.)  The fat-texture gives  evidence of anomalies both as to the contents
of the  fat-cells, and as to the properties of the cell itself.
   The cholesteatoma of Johannes Miiller  belongs to this class.  It is
invariably a local,  circumscript new growth.  The cholesterine holding
stratiform fat-mass consists of thin, sometimes  concentrically stratified,
mother-of-pearl like, lustrous plates of scales, which,  on a closer inspec-
tion, appear composed  of partly spherical and oval, but for the most
part polyedrical vegetable-like cells, one-eighth to one-sixteenth  of a
millimetre big.   This texture accords with that of the  tallowy, adipose
tissue of the wether, only that the cells are smaller and more  delicate.
The majority of  the  cells  do not  appear  nucleated; many  others,
however,  more especially the  younger  spherical  cells, show  distinct
nuclei.
   Between the layers of this polyedrical cell-texture are visible crystal-
line deposits  of fatty  substances, mostly  in the  shape of  rectangular
tables.   Barruel found them to contain cholesterine  and a  fat akin to
stearine.  The cholesteatoma commonly occurs encysted within  a fibroid
envelope, or within a  cyst-membrane lined  with a delicate  epithelium.
We have, in common with other pathologists, seen it thus in the subcu-
taneous areolar tissue, in bones,—those of  the  skull  in particular,—in
the pia mater, and in the brain.  Johannes  Miiller met with it in cysto-
sarcoma.   It also occurs free, in the shape of a layer, as Cruveilhier has
observed in urinary fistulae, and Johannes Miiller  and myself upon the
Surface of an  ulcerating mammary cancer.   In our own case  it was upon
the sore surface of a fibrous cancer combined with epithelial cancer.  We
have met with it in the same combination upon the surface of  a sloughing
ulcer.
   The cholesteatoma  is in  itself innocent.  Inclosed  within a cyst it
usurps the place of surrounding textures, causing the  forcible expansion
of the  osseous texture in bone, and occasionally  perforating the common
integument, when subjacent to it, becoming destroyed, and thrown off.
   3. Free Fats.—The  occurrence of  free fat,—a condition, we think, 
FAT-TEXTURES.
157
properly meriting the term of fatty disease—takes place under  different
circumstances :
   1.  It  is  immediately secreted as such.  The seat of its  deposition
are normal textures  and their  elementary parts, or else  pathological
growths.
   To the former category belong:
   (a.) Tallowy infiltration of the  liver, a condition in the  one instance
resulting from spirit drinking; in the other, being the  concomitant of
tuberculous disease.   In  the former case it is  often associated with a
stearine-like character of the contents of the adipose tissue.
   (b.) To the other mode  of occurrence belong more especially the fatty
contents of encysted tumors.
   These fats  differ in character.   Thus, in ordinary  fatty liver it is a
normal fat, for the most part rich in elain,—in  some varieties of fatty
liver,  the  waxy liver, a  more  consistent fat, containing stearine and
cholesterine.
   In various cysts, again, we meet with a fat consisting in different pro-
portions of elain, margaric, stearine-like fat and butyrine.  Some cysts
contain cholesterine alone; the majority, other ingredients besides.  In
this mode of its occurrence, fat is very generally associated with epider-
moidal and with osseous formation.
   2.  Fat, as such, is  liberated owing to new combinations  taking place
amongst the ultimate  constituents of a complex  formation.   Or, again,
it is not  set free as pre-existent fat, but is newly created, and this out of
protein substances, by dint of an elementary transforming power.
   This transformation or metamorphosis into fat  is rendered highly pro-
bable, if not certain:
   (a.) By the  large  proportion  of fat found  at various epochs in the
place of  parts, into whose  composition fat assuredly did not originally
enter in anything approaching to its subsequent amount.
   (b.)  By this appearance of excess  of  fat occurring under  conditions
which preclude its  derivation  from a vascular system.   It takes place in
growths destitute  of  bloodvessels  and often remote  from  vascularized
organs;  for example,  in  exudates,  shut up within thick shrivelled sacs
unfurnished with bloodvessels,—in  stratiform  deposits within  arteries.
It is even very commonly met with at the centre  of the said formations,
and therefore  at the greatest distance from vascularized parts; as, for
instance, in  the coagula,  within the vascular  system, in  tubercule-
granules, and in crude fibre in circumscript masses.
   (c.)  Lastly, by the appearance of fats in the said formations being the
forerunner of their entire metamorphosis, and generally speaking of their
destruction.
   For this adventitious production of fat, more especially as it  affects a
blastema in the progress of development, or even perfected textures, we
find the term fatty disease or  degeneration, peculiarly appropriate ; and
we consider it to be fraught with quite  enough of interest for general
pathology, to justify an attempt  to enumerate  here  the various phases
of its occurrence.
   1. Appearance of fat in the blood [or fibrin] coagula in veins,—the 
158
FAT-TEXTURES.
result of blood disease, either spontaneous, or consequent upon infection
by inflammatory products.
  2. The fatty conversion of coagula development through similar agency,
in the capillary system, as so-called depots—metastases.
  3. In fibrinous and  albuminous products of inflammation,—exudates,
and  especially pus.   This  is manifest in the exudates of  serous mem-
branes.
  4. In the albuminous, fibrino-albuminous products of Bright's disease
of the kidney.  The  spots  involved in the process of fatty conversion
are cognizable to the naked eye as dullish white, glistening,  for the most
part somewhat turgescent points.
  5. In lardaceous infiltration of the liver.  The lard-like blastema is
seen here and there opaque,—of a dull white or whitish-yellow.
  6. In tubercle, in incipient softening of the latter, and in like manner
in crude fibrinous deposits.
  7. In colloid, as  met with frequently in the thyroid gland.  In colloid
of the  more consistent kind,  it is discernible  with the naked eye as
opaque, dull-white  or whitish-yellow spots.
  8. In cancers, where it  enters  into emulsion-like  combinations with
albumen, as also into  saponaceous, glutinous conjunctions  with bases—
saponification of cancers.  The points de depart are here the yellow,
fibrinous masses which either traverse the cancer as a so-called reticulum,
or else  occur as circumscript accumulations.
  9. In atheromatous disease, in the strata that form upon the inner
surface of arteries,  and in the soft matrix of phlebolites.
  10.  In the. fibroid  blastema and texture, more  especially of fibroid
tumors and exudates.
  11.  In the annulo-fibrous tunic  of arteries, where it occurs,  either
pure or combined  with,  and dependent upon,  stratiform  deposits and
their metamorphoses—atheroma and ossification.
  12.  In the muscles, especially the involuntary, and the heart in  parti-
cular.   Here we  encounter an obvious conversion of the muscle-fibrils to
molecular fat,  with loss of the transverse striae and  inflation of  the
sheaths.
  Further  investigations are  necessary to determine  whether  milky
blood—the peculiar aspect of which is due to fat; and whether the pel-
let-like excretion of fat from the intestine, should be  classed along with
the above.
  This conversion into fat,  affects, as  we  have seen, now crude fluid and
solid blastemata, now  such as have attained to  various grades of tex-
tural development; finally perfected textures.
  The form or type under which the conversion takes place is  very  fre-
quent,  more especially in fluid blastemata.   It has been described  under
the head of " metamorphoses of blastemata."
  This process is in one sense to be regarded as a propitious  event, as
reducing certain growths to a condition readier for resorption and for re-
assimilation.  Moreover, it determines a state of involution,  isolation,
extinction of the involved growths.
 # In this latter property, it is often allied with  ossification and cretefac-
tion of blastemata and  textures,—processes  offering  many points of 
HORNY  TEXTURES.
159
analogy, and even of affinity with fatty disease from the disengagement
of pre-existent fat.   We need only advert to the cretefaction of crude
blastemata in the coagula of the larger bloodvessels, and in the capillary
system, in exudates, in pus, in tubercle,—to the ossification  and crete-
faction of stratiform deposits in the arteries, of the fibroid textures, &c,
—and compare this process with the collateral one of fatty conversion.
  Fats,  the product of conversion, may present much variety of cha-
racter.   In most  instances they are  fluid  fats  in  a  state of  minute
molecular subdivision, in larger, lustrous, strongly refracting,—or else,
in less bright, yellowish, tough  globules.  In  exudates, in tubercle, in
colloid substances, in cancers, and especially in the atheroma of arteries,
cholesterine is frequently encountered in a crystalline state.


              8. EPIDERMIDAL AND HAIR FORMATIONS.

  The excessive production over expansive  surfaces, both external and
internal,  of  epidermis, with  a  normal form  and  aggregation  of  its
elements, is often well exemplified, so  far as the mucous membranes are
concerned, in those of the oesophagus and vagina.   There are, however,
epidermidal luxuriations  besides, marked by several peculiarities, such
as site, circumscribed locality, unusual  aggregation  of elements.  To
these belong, also, the epithelial layers  investing the various cysts.
   (a.) As epithelial contents of encysted tumors.   The form of the cells
is most commonly that of tessellated epithelium cells.
  Upon the external skin these tumors manifest themselves as luxuriant
new growths, sometimes overspreading a wide surface, sometimes  limited
to a smaller space, occasionally as  cyst-like  developments  of  cutaneous
follicles with their excretory ducts.  These growths not rarely attain to
a  considerable  circumference,  and are distinguished  by a peculiar
anomalous arrangement of their elements, as also by, on  the  one side a
retarded, on the other  an excessive, horny character of the elementary
cells.
  (b.)  Clavus, a local accumulation of epidermis-cells, of a conical shape
with the  apex  pointing to the interior of the papillary body, with a
superimposed disposition of the cells not deviating from the normal.
  (c.)  Warts.—Of these there are sundry varieties.   The most ordinary
consists of cornified  epidermis forming a sheath-like receptacle of con-
siderable  thickness  for the hypertrophied cutaneous papillae.   Others
are marked by the  elongated  fibrous  arrangement of very luxuriating
cells, as  polyedrical,  edged cylinders  in parallel array, some of which
show imperfect cornification.   They have a fibro-villous, appearance, are
humid, and readily broken up  by pressure into fibres  and their elements.
Their cells are devoid of nuclei, and in  only a few instances cornified.
  (d.) Ichthyosis.—The higher grades alone concern us here, the epi-
dermis  covering a papillary body, proportionately hypertrophied, luxu-
riates  into polyedrical  tessellse,  cylinders, and disks.   The disposition
of the cells, at least  in the cylinder form, is  a fibrous  one, parallel to
its length.  The degree of cornification is not in every case the same.
  (e.) Horn—cornu cutaneum—a very common, for the most part dingy- 
160
PIGMENT  FORMATION.
brown, longitudinally ribbed, more or less curved, cylindrical or conical
horn-growth, springing from a cutaneous  follicle  of  cyst-like  develop-
ment.   It attains now and then to several inches in length.  Its structure
is seemingly fibrous.  The cornification of the cells is  very marked.   It
affects parts abounding in follicles, or hairy surfaces and  their vicinity;
for example, the forehead, the neighborhood of the pubes, and again, the
back and the upper extremities.
  All these growths are in their nature innocent.
  Besides these, however, there occur upon the common integuments,  as
also upon the mucous membranes, growths which, although  often extir-
pated with a favorable result, occasionally  prove malignant  and assimi-
late in all respects to cancer.   Their elementary cells  repeat the form  of
the non-cornified, nucleated, tessellated epithelium-cell, not rarely with a
fibre-like prolongation, and whose secondary arrangement often displays
the areolar type, or  else  represents in fibrils a moist velvety growth,
similar to hypertrophied cutaneous papillae.
  Anomalous hair occurs  in various shapes with  reference to the form,
color, length, and thickness of the hair-cylinder.
  Besides  their appearance at unusual points  of the external integu-
ments, especially upon pigment naevi, we have to advert to—
  (a.)  Hair contained  within encysted  tumors.   This  is commonly
mingled with fat and epithelium.   It is extremely frequent in the fatty
cysts of the ovaries, but is also found in those of the omentum,  of the
cutis,  of the subcutaneous areolar tissue, and even of the lungs.  In these
cysts it is  often found to pervade the fat, as with a felt growing  out  of
variously-sized  patches, closely resembling the cutaneous texture, from
the inner surface of the sac.  Its development is here seen to be entirely
identical with that of hair upon the common integuments.
  (b.) Hair upon mucous  membranes. It has been detected upon various
mucous membranes, including even the conjunctiva of the eye.
  Very small, partly microscopical, hairs are sometimes mixed  up with
the contents of encysted  tumors,—with cholesteatoma.   Those said  to
occur in the different secretions,  the urine for  example, are evidently
derived from a mucous membrane.

                      9.  PIGMENT FORMATION.

  Irrespectively of all other anomalous  coloration, but with  a retrospect
to that conversion of blood-pigment alluded  to under the head of hemor-
rhage,  we  shall here treat  of granular pigment.  It appears  under
the various shades of jet, of Indian-ink black, of  russet, or  of a yellow-
brown.
  It occurs both  free and enclosed within cells, in the shape of very
small, spheroidal, scattered or clustered granules, together with rod-like
molecules  (with molecular motion), or else in the  shape of larger spheri-
cal or spheroidal, in like manner either  scattered or intimately  grouped
and blended corpuscles.   The cells are for  the most part spherical, but
in certain conditions, as  in  cancer melanodes, spindle-shaped,  caudate,
rarely twigged.
  These various modes of occurrence, together with the several shades 
PIGMENT  FORMATION.
161
 of the pigment enumerated, are, as we shall afterwards see, partly phases
 of development of the pigment, partly due to external conditions.
   It hardly ever occurs quite pure  between the elementary parts  of a
 texture.  Generally speaking, it adheres to a blastema at  some period
 of textural  development, for instance, to inflammatory products, adventi-
 tious membranes, colloid, malignant growths (melanosis).
   When small in quantity and equably  distributed, it  determines slate-
 gray coloration of the textures, or a speckling  or  streaking with black
 dots.   It may, however, manifest itself  in  larger  knotty  accumulations
 so as to consolidate and lay waste the textures, as for example in the
 lung.
   It affects the fluids also.
   Before speaking of  its origin, it is requisite to pass in  review, as a
 simple  series of facts, the several cases of its occurrence.
   lit, normal textures, the sequence of its amount and frequency is nearly
 as follows:
   1. In the lungs, its seat is  the true pulmonary  texture, but also the
 interlobular areolar tissue.  When inconsiderable in quantity, it lightly
 marbles the parenchyma.  When abundant, it forms  greater, branched
 accumulations, and along with these, distinct solitary masses of from a
 hempseed to a bean in size, and presenting a cut surface of dull metallic
 lustre.   Or, again circumscribed patches of the parenchyma, especially
 at the  apex, may be so replete  with it as to display it  as a coherent,
 black, hardened, impervious mass.   It is particularly redundant around
 shrivelling, cretefying tubercles, healing cavities and  cicatrices  at the
 apices of the lung. It is for the most part found pure, free,  in the shape
 of a minute molecule, unattached to any ostensible blastema, and certainly
 very seldom contained within  cells.
   In manhood  and old age  it is  but a physiological product.   In the
 earlier periods of life alone, as those of boyhood and youth,  or when by
 its quantity it proves destructive to the  pulmonary texture, is it to  be
 regarded as a morbid phenomenon.   The notion of its being peculiar to
 old  age is  correct only in so far  as, in  the aged, it is  for explicable
 reasons hardly ever absent.   It does not, however, by any means  belong
 exclusively to this period of life.   If it almost invariably abounds in the
 old,  it is because in them there has  been ample time for its accumula-
 tion.  Still  it is undeniable that the condition of the blood  in advanced
 age, with its augmented proportion of blood-corpuscles,  and  its simulta-
 neous diminution of fibrin, must essentially favor the deposition of this
 substance.
   2. In the bronchial glands, from a speckling and extensive marbling
 up to the point of considerable increase of volume in the gland, and its
 conversion  into a hard Indian-ink-colored tumor, in which the glandular
 parenchyma has perished.  Its amount is here commonly  proportionate
 to that  in the lungs.   Its form is that of free molecule, very rarely of
 molecule contained within cells.
   3.  Gastric and intestinal  mucous membrane.  In the shape of free
molecules, often coherent in larger masses.   It  occurs thus  both in the
muco-membranous texture itself, more particularly at the great concourse
of the solitary and of the aggregate glands, as also in the intestinal villi,
  VOL. I.                           11 
162
PIGMENT  FORMATION.
imparting to the mucous membrane an aspect, to the naked eye, of being
lightly brushed over with  black, or uniformly tinged  of a slate-gray.
Where the accumulation of pigment is considerable, the part appears of
a blackish gray, or it may be of a deep black.
  In rarer instances, the tracheal and bronchial mucous  membrane is
pigmented—that of the uterus frequently.
  In the majority of cases it  accompanies the more intense  chronic
catarrhs (blennorrhoeae) of  the stomach and intestines.   When affecting
the intestinal glands, it points to antecedent hyperaemia, stasis, and ex-
udation—typhus, for example,—at every age, even  in delicate children,
to a diarrhoea-like  process in the follicles of the colon.
  4. In the mesenteric glands, it is for the most part limited in amount,
and concurrent with pigment in the intestinal mucous membrane.  Here,
again, it is a sequel to  typhous hyperaemia and effusion.
  In other lymphatic glands, the seat of hyperaemia, hemorrhage, inflam-
matory  stasis,  and exudation, it is less frequent.
  5. In the central ganglia of the abdominal sympathetic, more espe-
cially the ganglion of the solar plexus,  usually combined  with  wasting
thereof, as a sequel to typhous hyperaemia.  For the most  part small in
quantity, has  a  uniform,  pale,  slate-gray coloration,  or  is  visible  as
blackish dots or striae.
  6. In the common integument, as the so-called melasma of  the old or
cachectic, as a diffuse suffusion of the common integument with pigment,
in the lower extremities, and  as knotty pigment accumulations in the
face.
  In new growths:
  1. In the blood-coagula in arteries, veins, and capillaries (metastases),
whether spontaneous or due to inflammation of their coats, and termi-
nating in their transmutation to  fibroid shrivelling cords and cicatrices.
  2. In atheroma  that has discharged itself into the  canals of arteries,
and  especially in the depSts and cicatrices formed in the act of its excre-
tion.
  3. In the membranaceous growths investing hemorrhagic  depdts, as
also in the contents of hemorrhagic  cysts, being here of a russet or yeast-
color.   The black  pigment found in the  shrivelled  and extinct  ovarian
follicles, after  elimination of their contents  (during menstruation), is here
deserving of mention.
  4. In inflammatory  products upon  serous  membranes, as a  black
pigment, upon the peritoneum, more commonly of  a brown, or rust-color
upon the tunica  viginalis  testis, upon  the  pleura, the  pericardium, the
arachnoid.  It adheres to the exudate from the commencement, that is,
from its crude condition, through all its phases of textural development,
up to the areolar or the fibroid structure.  According to its proportion,
it manifests itself  as spotted, striated, or  uniformly slate-gray, bluish-
black coloration,—always occurring as free pigment molecule.
  It is  more rare in the inflammatory products of parenchymata.  Scar-
textures are, however, not exempt  from it, even in the  common integu-
ments.
  To its appearance on serous membranes  we have  to add that detected
upon the inner membrane of cysts,  and of  the cyst-like developments of 
PIGMENT FORMATION.
163
various  hollow organs  and canals—for instance, upon the inner surface
of the dropsical Fallopian tube sac.
  5. In tubercle, that is to say, the hemorrhagic tubercle, both in paren-
chymata and upon serous membranes.
  6. In colloid,—mostly as a brown tint.
  7. In cancer melanodes (commonly called melanosis, malignant mela-
nosis), a heterologous  growth,  consisting  of medullary carcinoma with
pigment.   The  brown and black pigment is  here partly free, partly
contained in cells, with the character of  cancer cells.   The medullary
carcinoma is in various degrees spotted or striated with the pigment, or,
in fine,  so replete with  it as to appear throughout dark  brown or black.
(See Cancer melanodes.)
  In fluids:
  1. In the fluid portion of the exudate in serous sacs.
  2. Mingled with  the contents  of the  larger cysts,  and of hollow
organs  in process of cyst-like  development;  for example, the dropsical
tube-sac.
  Finally, it occurs under several special conditions, as:
  1.  In the black substance present in acute softening of the stomach;
in the black contents of the stomach and intestines generally.
   2.  In the pulp constituting the rare black softening of the spleen.
   3.  In the detritus of necrosed textures,  especially in dry gangrene,
or mummification.
   4.  In the  parietes  of ill-conditioned  abscesses—ichor  dep6ts;  but
most of all at the margin and base of every variety of intestinal ulcer.
   This  preliminary will serve  as a useful starting-point for  an inquiry
as to the groundwork  of pigment, and the  conditions  upon which its
appearance depends.
   That the groundwork of pigment is the coloring matter of the blood
appears to us  proved, the  cases in which pigment  is obviously derived
from haematin and blood-corpuscles  being so numerous as to exclude all
doubts on the subject.   Still the circumstances by which the conversion
is brought about, and still more the various shadings of the pigment, are
unexplained.
   The  cases in which  the  metamorphosis of blood-pigment—that is of
blood-corpuscles into  pigment—is manifest, are of the most  common
occurrence.   Such are the cases of hemorrhage,  and of hemorrhagic
exudates in serous sacs, more particularly the peritoneum, of hemor-
rhage from intestinal  ulcers, of pigment development in blood-coagula
within vessels, of black  or dark-colored  softening of  the  stomach, of
black contents of the stomach and intestines generally, &c.
  But  hemorrhage, whether   simple or  combined with inflammatory
exudation, cannot, in  all  instances,  be assumed, still less proved.  In
the other cases,  therefore,  where pigment occurs, for  example, in the
lungs, the  lymphatics, &c, we  must, whilst still holding on to the belief
that haematin furnishes the groundwork of the dye, look around us for
some further mode of  elucidating the mystery.
   The  pigment may,  independently of any development out  of extra-
vasated blood, be brought about through—
  1.  The obliteration  of small bloodvessels  or capillaries, with the con- 
164
PIGMENT  FORMATION.
 version  to  pigment of their  contained blood, just as the stain is pro-
 duced in  plugging blood-clots  within the  greater  vessels.   As  the
 vessel's parietes disappear through absorption, striated accumulations of
 pigment corresponding to the course of the vessel, are entailed in the
 textures.  This takes  place more particularly in membranaceous areolar
 tissue formed upon serous membranes previously vascularized.  In these
 the opportunity sometimes offers of tracing the aforesaid process.  Even
 the  pigment in callosities entailed by so-called  capillary phlebitis  may
 be partly brought about by the same  means, namely, by metamorphosis
 of the blood-coagulum in the vessels destroyed.
   2. Through conversion to  pigment of the  blood in  different blaste-
 mata, especially the products of inflammation and cancer melanodes.
   3. By transformation  of the blood-pigment  along  with  other  sub-
 stances in the  normal act of nutrition, or in consequence of  hyperaemia
 and inflammation.   The probability of this event will be relative to the
 predominance of the blood-corpuscles in the circulation generally, to the
 number of old and very highly colored globules present, and lastly, to
 the  extent to  which their coloring matter is taken up  by the plasma
 when attenuated through  the diminution of its salts, or  the  destruction
 of its fibrin.   In this manner it is intelligible how pigment may become
 engendered without the extravasation of blood-corpuscles, how it so often
 becomes deposited in  the lungs, as the central  receptacles  for venous
 blood, how the aged are  peculiarly prone to its deposition, and lastly,
 how in certain erases,  the typhous for example, it so frequently attaches,
 as the residue  of hyperaemia  and inflammation,  to the follicular appa-
 ratus and the mesenteric glands.
   It would  seem to  have  arrived at certain organs partly through re-
 sorption—the bronchial glands, for instance.
   Our own investigations concerning the morphological  process of pig-
 ment formation have led to the following conclusions :
   The pigment differs  according as its basis consists of hgematin alone
 in a state of solution, or of blood-corpuscles.
   In effusions reddened by dissolved haematin, the pigment separates as
 a result both of the changes produced by resorption, by the accompany-
 ing menstrua,  and  by consolidation,  and also  of  probable  external
 agencies effecting coagulation or precipitation in the shape of a granular
 mass (of discrete or  agglomerated molecular granules), which imparts a
 brown, a yeasty, or black coloration.
   Where blood-corpuscles are actually present, either these become dis-
 solved, and the development of pigment out of the coloring matter takes
 place as in the foregoing case; or else the haematin becomes pigment
 within the blood-corpuscles, which thereby become  transformed into
 mulberry-shaped  corpuscles.   These remain  separate, or  cohere in
 groups of two, three, or four,  or  they may even  gather together into a
 lobulated mass.  Earlier or later they break up into  the molecular pig-
 ment-granules before adverted to.  Under both forms and modes of de-
 velopment the pigment is, to a greater or less extent,  contained in cells.
 Upon this point, experience has shown us that—
   1. Pre-existent  nucleated cells (of various forms) take up  hgematin,
which, as the contents of the  cells, becomes molecular  pigment.   This 
PIGMENT  FORMATION.
165
is, perhaps, a  repetition of the process that  takes  place  in normal pig-
ment formation.
  2. One or more  mutually coherent blood-corpuscles constitute, as it
were, a  nucleus-formation,  around  which a  cell-wall  developes  itself.
Even within this cell the nucleus-mass may break up into  molecular pig-
ment.  The haematin frequently associates itself, dissolved, to the cell's
contents,  and there coagulates to molecular pigment, whilst the now
colorless  nucleus-mass (blood-globules) undergoes, probably in its protein
contents  (globulin), conversion into fat-globules.
  3. A cell-wall forms around a conglomeration of molecular granules.
  These  are frequently all  concurrent processes, just as happens with
pigment  formation  external  to  cells.  The  two former  processes are,
however,  both attested in colored  exudates, and most particularly in
cancer melanodes.   In either  way,  a  sort of pigment granule-cell  is
brought about.
  The precise manner  in which the conversion  of  haematin  to pigment
takes place, is obscure, if not altogether unknown.   It cannot be doubted
that the  haematin  undergoes various and considerable  changes.   Some
indications in  point are seemingly derived from the conversion of haema-
tin into pigment, through the palpable influence of chemical  agents, ad-
dressed,  sometimes to the   haematin itself, sometimes to the iron  it
contains.   Strong mineral  acids (sulphuric, for  instance)  introduced
from without darken or blacken the  blood with which they come in con-
tact.  Carbonic acid gas (evolved, along with carbonic  oxide gas, out  of
glowing charcoal) acts in the same manner upon the capillaries when a
stream of it traverses the fauces; and a similar influence is exercised by
acid secretions generated in the organism itself,  as  we have ^een in
alluding  to colored  softening of the stomach.
  Like the blood itself, the  kindred spleen-pulp (spleen-corpuscles) suf-
fers the same  transformation of  its  elements.   The change of color is
here most probably determined  through the combination  of haematin
with different  acids, carburet, chloride of haematin,  &c.
  The very frequent  conversion of red hemorrhagic exudates upon the
peritoneum into black strata, is most probably founded upon the influ-
ence of the intestinal gases upon the haematin.   In common with ammo-
niacal  gas,  it is  principally the  sulphuretted hydrogen  of the bowel
which, acting  (by exosmosis)  upon the iron of the haematin, enters with
it into  a black combination, namely,  sulphuret of iron.  A similar effect
is wrought by  phosphuretted  hydrogen in abscess and gangrene.
  Fertile in results as are the above  anatomical data relative to the fun-
damental principle of pigment, they seem to throw very little light upon
the chemical processes by which the  conversion of haematin is regulated.
The influences adverted to under which  haematin blackens, admit of  no
ulterior application.  We are still reduced to the entailed general view
of defective decarbonization of  the  blood, to which the  abundance  of
carbon detected by analysis  in the various black substances, certainly
adds weight.
  But even shduld  the pigment, as Guillot affirms, of the black pulmo-
nary artery, consist of pure carbon, this  would in nowise  refute  our
theory, namely, that it is invariably  developed out of haematin. 
166
COLLOID.
  Although  russet-and yeast-colored  pigment  are  obviously derived
from the same uniform base with black pigment, yet the conditions upon
which  the existence of this pigment depends  are little known, and its
composition still less.   Thus much is certain, namely, that in color it is
susceptible both of deepening into blackness,  and of fading into pale-
ness.                                                          .
  Generally speaking, an organ is liable  to become the seat of pigment
formation proportionately to its vascularity, to its proneness to hyper-
aemia,  inflammation, and hemorrhage,  and to  the extent to which its
blood-supply is marked by excess  of  coloring  matter, that is, by the
venous character (Venositat).
  The resorption of granular pigment is a fact!  How this takes place,
—how and whereby it becomes adapted for the process,  is not known.
  In itself pigment is  an innocent new  growth.
  It is still of some importance to inquire what is to be thought of the
distinction of pigment into true and false melanosis.   Seeing that pig-
ment  has,  under  all  circumstances, one and  the  same fundamental
principle (haematin), and that our knowledge of its workings is limited,
the distinction seems supererogatory.   Which is the true and which the
false ?
  We  deem it most advisable to abolish the word  melanosis altogether,
and to substitute  for  it the term pigment,  designating all  growths,
normal or pathological, into whose  composition  pigment  enters, as pig-
ment-holding  or   pigmental,  and  what has been  called  malignant
melanosis, as pigmental cancer,  or cancer melanodes.

       •                     10.  COLLOID.

   Colloid, colloid  substance, is  a sufficiently common heterologous for-
mation.   It is  requisite, however, to  state, that  under this term sub-
stances have been  brought together which, in a physical and  chemical
respect,  are not perfectly uniform;  for instance,  the  colloid of the
thyroid  gland, the substance of collonema, on the one side, and on the
 otlier, gelatinous  cancer.   Further inquiry may, however,  show  such
 differences to be but modifications and gradations of the same substance.
   Moreover, the occurrence of  colloid  abuts so closely upon the physio-
 logical,  that it is  difficult to define its  pathological significance.   Thus,
 it accompanies the often mere passing development of the thyroid gland,
 the secretion of certain follicles undergoing occasional cyst-like develop-
 ment, especially at the cervix uteri; and again it forms the contents of
 glandular growths in  the progress of cyst-like dilatation.   In  other in-
 stances  the  appearance of  colloid is too obviously of pathological import
 to  admit of any doubt.  It constitutes  both innocent and malignant new
 growths.
    Colloid is a semi-fluid adhesive  substance, resembling a saturated solu-
 tion of gum or glue, or a fruit  jelly.   It is seldom  colorless, ordinarily
 of a honey or pale wine-color, but often brown, or  green, sometimes
 black.  With all these  tints it  is clear and pellucid, and only now and
 then  turbid,  flocculent.   Microscopically  examined,  it  displays, in
 smaller or greater number, elementary granules, nucleated forms, nucle- 
COLLOID.
167
ated  and non-nucleated  cells,  together  with parent-cells,  in rare in-
stances (even in colloid of the thyroid gland) the pouch-like formations
mentioned under the head of metamorphosis of blastemata, and  even
caudate cells.
   With  respect  to chemical  composition,  the  reactions  are those of
various gradations of casein, of pyin, of certain kinds of mucus.
   Colloid is, for the most part, found accumulated in hollow organs, in
follicular, alveolar, cystoid spaces, and so seldom free within  a texture,
that the former mode of its occurrence has been regarded as pathogno-
monic of its true character.
   1.  It is most frequently met  with in the thyroid gland, so frequently,
indeed, that few thyroid glands are examined in which more or  less of
it  is not here and there detected.  It  is  accumulated  in the cyst-like
dilatations of already existing acini, as well as in others of new growth.
The disease represents lymphatic, and in further development, cystic
goitre.   It occurs,  moreover—
   2.  In simple cysts (whether  new growths or morbid developments of
pre-existent hollow  organs, for example, cysts of the kidneys consecu-
tive to Bright's disease), and also in compound cystoids,—of  the ovary,
for instance.
   3.  In the pituitary gland, as a pale amber-colored layer  interposed
between its two lobes, believed by Wenzel to be the cause of epilepsy.
   4.  In serous sacs, as a remarkable transformation of a fibro-croupous
exudate into colloid.  Andral has witnessed this  in a pleural, and we
ourselves in peritoneal exudates.
   5.  A colloid substance constitutes collonema, and its kindred, benign,
new growths.   (See Sarcoma.)
   6.  A colloid resembling the vitreous secretion of mucous follicles forms
the contents of alveoli, and of their endogenous  cysts, in innocent and
malignant new growths,—sarcomata and cancers, especially true alveolar
cancer.
   A question  of great interest is, whether colloid is secreted as such.
   (a.) Several facts, especially the appearance of colloid  in the  Mal-
pighian bodies of the kidneys, but likewise the transformation  of the
aforesaid exudates into colloid,  afford  conclusive evidence  that, under
some unascertained conditions, albumen  and fibrin  become  converted
into colloid.
   (b.)  Other facts render it probable that  it is the product of  an altered
function of secreting gland-cells,  or of the  action  of anomalous cells,
parent-cells, aveoli, and cysts.
   (c.)  The colloid of the thyroid gland in its voluminous occurrence, as
endemic goitre, merits an attentive consideration on account of its cha-
racter of exclusiveness in relation to tuberculosis.   The alienated habit
of body acquired in endemic goitre,  may, indeed,  be indicative  of a
change in the crasis ;  although as to the nature of such change, its rela-
tion to the function of the thyroid gland, and its character of antagonism
with tuberculosis, we are altogether in  the dark.
   Colloid undergoes many spontaneous changes.   Besides its resorption,
as observed in colloid of  the thyroid gland, it  becomes, in  cyst, diluted
by the thin secretion from the cyst-wall,  or  else, under gradual extinc- 
168
CYST.
tion of the cyst, condensed, and  eventually changed into a  brittle sub-
stance resembling dried glue.   Lastly, it achieves—
  (a.) A remarkable  conversion  to  molecular fat, becoming yellowish,
turbid, opaque, and unctuous (colloid of the  thyroid  gland,  gelatin of
alveolar cancer).
  (b.) In a few instances, cretefaction,—in colloid of the thyroid gland.
These cases are, however, quite distinct from the cretefaction and ossi-
fication of fibrinous exudates within the strumous thyroid gland.

                      11. CYST  AND ALVEOLUS.

  In  asserting cyst to be a substantive new  growth, with a  distinctive
elementary groundwork, we exclude all accidental cyst formations, that
is, capsules  and sheaths  forming around foreign bodies, extravasate, or
entozoa (cysticercus,  for example); as also  cyst-like  disease of hollow
organs consequent upon the closing and obliteration of their excretory
ducts and orifices,—for example, in  the gall-bladder, the Fallopian tube
and uterus, the vermiform appendix,  the  sebaceous and muciparous
glands.   Certain gland-elements, however, and in particular those of the
thyroid  gland, demand  an especial consideration, inasmuch as these
hollow bodies represent a certain stage  in the process  of cyst formation,
having the same elementary structure, and being susceptible  of ulterior
cyst-like development.
  Let us begin with the results of an examination with the naked eye of
perfect cysts, and in particular of the exquisite specimens so  frequently
met with in the ovaries.
  We have the simple (unicancellated) and the compound cyst (Miiller's
compound cystoid).   The first  is sufficiently characterized by its name.
Compound  cysts  declare  themselves  by phenomena  which  induced
Hodgkin  to distinguish  them  in two  classes, although  types  of  both
very commonly coexist  in the  same formation.   The first comprehends
a cyst-formation with cysts of a secondary order in the parietes of a volu-
minous (parent) cyst; and these secondary cysts involve, in like manner,
cysts  of a tertiary order within their parietes.  These filial cysts project
upon  the outer surface of  the  parent cyst, rather than upon its inner
surface, where  they are  in a degree flattened.  The wall of the parent
cyst often appears separated, receiving the secondary cyst, as it were, in
a chink.
  Such a formation is to be distinguished from a group of simple cysts
developed in mutual juxtaposition,  some one of which predominating in
size, flattens the contiguous smaller ones.  A group of smaller cysts in
an ovary may readily mislead ; making it seem as if the fibrous capsule
of the ovary were but the wall of  a cyst, and as  if  the  smaller cysts
interposed  between  it  and a  contiguous  larger one, were  secondary
cysts.
  The repetition of this  process of secondary cyst-formation  frequently
leads  to a very complex cyst-formation, wherein, however, for the  most
part,  a cyst pre-eminent in size,  reveals itself as the parent or  primary
cyst in whose parietes the cysts  of  the second order become  developed.
Sometimes the primary cyst is so prolific  of this secondary cyst deve- 
CYST.
169
lopment within its  parietes, as to endow the latter with a  considerable
thickness.   It may even cause them here and there to degenerate into
a tumor,  consisting of an aggregate  of cysts, collocated like facetted
pouches in  the breadth of the cyst-wall, and  presenting a  polyedrical
cell-structure, in and upon the walls of which smaller cysts arise.   Occa-
sionally a cyst-wall, so constituted, further degenerates (owing to a rup-
ture of the  secondary cysts, and  to their bursting into the cavity of the
parent cysts) into a multilocular cell or network.
  Every cyst is of  course competent to represent a parent cyst in rela-
tion to its own ulterior cyst production.
  The  second category comprises cysts in which secondary cysts arise
upon the  internal surface of  the parent cyst, and grow into its cavity.
They are  sessile upon a broad base,  or more often upon a  neck or pedi-
cle ; in which case they mostly represent pear- or wedge-shaped tumors.
They often  so luxuriate in number, and at the same  time grow to such a
size  as nearly to fill a parent cyst of  considerable magnitude.  In rare
instances, a solitary cyst of this kind so increases as singly to fill up the
space of the parent  cyst,  causing the sac to consist,  down to the base of
the filial cyst, of two contiguous  layers.
  These secondary  cysts become developed in the internal layer of the
parietes of the parent cyst, and have a sheath derived from the internal
membrane,  from which the secondary cyst can, with care,  be separated.
In the pedunculated, pear-shaped cysts, it furnishes, in a state of involu-
tion, the pedicle into which the pouch, or wedge-like cyst, projects with
a conical  tapering end.
  They are either simple or compound,  according to one or other type.
In their wall, namely, reside cysts of  an ulterior, that is, a tertiary for-
mation, which grow more or  less  outwardly or inwardly;  the former
acquiring  a shallow-lobed, blackberry-shape,  and appearing cellular
within.   The pear-shaped cysts commonly consist of several parallel
pouches of various  lengths.   Along with these are found, on the inner
surface of the parent  cyst, in varying numbers, the  smallest vesicles,
just  cognizable with the naked eye.   In one  instance these were found
on the  inner surface of an extensive ovarian cyst, mixed up with, for
the most  part,  naked  yellowish incrustations  the size of a poppy- or a
millet-seed.
  The difference between these two types of  the compound cyst is ob-
viously  not essential, but depends only upon the seat of development of
the secondary cyst.   Hence, the very common concurrence of the two
types.
  There also occur,  on the  inner surface of the cysts, both parent and
secondary, ramified  cauliflower  excrescences, flattened, or fungoid,  or
pedunculated.  These  are scattered  singly,  or grouped  together,  or
knotted in masses.   Sometimes they luxuriate in and by the side of the
said secondary cysts, to  such an extent as to fill  both these and the
parent  cyst, rupturing the latter, and, in the  frequent cases of ovarian
cyst, invading the peritoneal cavity.   In the ruptured secondary cysts
we  often  recognize  their sheaths folded back, and reflected over  the
cauliflower vegetation. 
170
CYST.
  Besides the variations alluded to, there is much that is worthy of note
in and about these excrescences.
  1. They consist of a very delicate membranaceous growth folded and
rolled  up in their pedicle, projecting about and especially above  it in
various ways, branching  out into  numerous villous and  bulb-like  pro-
cesses, or into the semblance of a plaited frill.   Upon the said processes
are again seated delicate  villous flocculi.   They are highly vascular, and
have a blood-loaded  aspect.
   2. Here and  there they frequently carry, especially at the extremity
of their branchlets, a just cognizable, poppy-seed-sized, limpid,  or semi-
opaque vesicle,  or a  hemp-seed-, or a pea- or bean-sized cyst.
   3. More frequently still they bear upon their twigs solid, though soft,
whitish,  roundish, or,  from mutual  compression,  indistinctly  facetted
corpuscles ; or else tougher, white, opaque tubercula, mostly of the big-
ness of millet or hemp-seeds.   Here the entire excrescence is commonly
white, the  small broad-based  ones  resembling delicate stellar horny
warts, whilst  the larger and more extensively clustered  ones constitute
an unyielding  tumor, superficially stellate, studded with  the aforesaid
tubercula upon  its peripheral villous structure, permeated throughout its
cut surface  by fibrous threads (the pedicles).   In this tumor, the blood-
vessels have become destroyed.
   4.  Besides the more extensive  excrescences, smaller  ones  are  com-
monly seen, resembling a nap  of extremely delicate villi, or of finely
pedunculated tubercula.
   5.  At the same time the  internal investment of the cyst has, in ex-
panded parts, often  a very finely reticulated aspect; or it reveals very
minute fissure-like grooves, not a few of which are surrounded by an
elevated ridge-like brink.   Out of these is here  and there seen  to rise a
simple or branched  excrescence.   In other places, the internal layer of
the cyst-wall is  seen raised into a flattened vesicle, which, like  the  said
grooves, often displays minute fissured openings.   Internally  is some-
times plainly discerned a convoluted mass of bulb-shaped excrescences,
or else a very minute network.
   With  these are  associated  larger vesicles, rising into pedunculated
wedge-shaped pouches, which contain a very delicate  cancellated struc-
ture, and frequently exhibit roundish or angular chink-like openings, out
of which delicate felt-like excrescences occasionally project.   The size
of the cysts varies greatly from that of a just cognizable vesicle to that
of a sac of from 1 to 2 lines in diameter.   The  compound cysts may, of
course, attain to a very considerable magnitude, a notable portion always
appertaining to the  parent cyst.
   The free space of the cysts  hitherto described, is commonly  occupied
by a serous synovia-like, or a thicker glutinous, or glutino-lardaceous,
so termed,  colloid moisture.
   Examined under  the  microscope, the  following  additional light is
thrown upon the above appearances.
   The cyst-wall consists of densely-reticulated areolar  tissue, the in-
ternal layer constituting an epithelium of cells or nuclei.   In large cysts
this is, for  the  most part, absent, and the internal layer generally pre-
sents  a  nucleated,  structureless, or  striated blastema, at the  circumfe- 
CYST.
171
rence of which  the oval nuclei are in  the act of splitting into fibres, in
the direction of their long axis.   On examining a section of the internal
layer of  a cyst-wall,  from a  part furnished  with vesicles  (secondary
cysts), we obtain a view like that presented by the cortical substance of
a kidney  affected with cyst-formation, to  the consideration of which we
shall shortly have to  recur.  The same nidus often contains concur-
rently incrustations, in  some  instances  remarkable  for  their  size  and
figure.  On  examination, the  excrescence appears as a hollow growth,
consisting of a transparent structureless membrane, studded with round
or oval nuclei, often striated, especially at the pedicle, and breaking up
into delicate fibrils, with numerous spheroid protuberances.   These be-
come developed  into pouches, mostly bulb-shaped at  the extremity,  and
by  throwing out secondary protuberances  and pouches, complete  the
branchlets and  twigs of the excrescence.  They  may be invested with
the epithelium of the cyst-wall, or even uninvested.   They are furnished
with conspicuous bloodvessels, which, running  along  the  protuberances,
describe extensive arches and anastomoses, and frequently become  the
seat of aneurismal dilatations, or the source of hemorrhagic effusion  into
the cysts.  In their interior they contain nuclei in various numbers,  and
along with these, especially near the blind  extremity of the  branchlets,
growths which turn out to be young cysts.
   These young  cysts dilate into those spoken of as cognizable with the
naked eye.
   The  minutest excrescences appear as simple,  smooth,  or tuberous
hollow bulbs.   The internal layer of a cyst-wall, presenting  the reticu-
lated texture described (5), appears, when magnified, in the  form of
elongated, round, angular, distended meshes, through which  the simple,
smooth  bulbs penetrate as they grow.  The cancellated framework,
contained within the described vesicles, consists of  a  hyaline,  structure-
less  membrane,  studded with  nuclei.  It has unquestionably arisen out
of the fusion of several bulbs.
  The excrescence, as described  at  No. 3,  arises  through the develop-
ment of areolar tissue out of  a transparent amply nucleated blastema.
In its cavity are lodged, sometimes in vast quantities, simple and lami-
nated, semi-opaque, incrusted growths, from the size of an elementary
granule to a diameter of 55th  of a millimetre, the circumference, most
common to incrusted cysts.
  The excrescence simultaneously becomes fibrous,  and shrivels, with
condensation of fibrous parts, into the solid masses above  described.
  In these observations, two phenomena engross our  attention, namely,
the development of the secondary cyst and the  hollow growths  forming
upon the internal wall of the cyst.  We have made them the subject of
an  extended investigation, with  a view  to  the solution  of the double
question as to the nature of elementary germ for cysts, both primary  and
secondary, and of its ulterior development,—and as to the import of the
said hollow growths.
  (a.) The cysts best adapted for the inquiry, are young, small, clustered
cysts, just visible to the naked eye ;  others being probably present,  still
smaller, down to the germ itself, out of  which  they  spring.  The cysts
so frequent in the kidneys, or on  the  broad ligaments, and on  the 
172
CYST.
peritoneum of  the tubes and ovaries, furnish ample materials for the
purpose.
  1. In the cortical substance of the  kidneys, especially during the
decline of Bright's  disease,  a  luxuriating cyst-formation  is  not un-
common.
  In  the dimpled  depressions  upon the  surface of atrophied, gibbous
kidneys, reside entire nests of parallel-clustered, just discernible, poppy-
or millet-seed-sized vesicles, imbedded in a reddish-gray, or whitish nidus.
Occasionally the kidney is found altogether degraded into an aggregate
of various-sized cysts.
  A small portion of such a nidus placed under the microscope, displays
along with the ddbris of renal texture,—namely, uriniferous tubules and
Malpighian tufts, in a state of collapse or involution ; the former denuded
of their epithelium, and  here  and there  replete with  fat  molecules—
a multitude of cysts invisible to the naked eye.  The more marked have
parietes, consisting  of  fibres beset with  elongated oval  nuclei, which,
more particularly about the inner fibre layers, bend round  towards the
circumference  of the  cyst.   These cysts  are replete with  granulated
nuclei,—now and then with spherical or polyedrical  cells, to  which, in
some  few, is  superadded a molecular  mass,  partially betraying by its
brown coloration its character as pigment granules.
  In some cases  this occupies the centre  of the cyst, where  the nuclei
become  indistinct and  disappear.   In some cysts,  the nuclei (or cells)
are reduced to  an  epithelial formation investing the cyst.   In others,
again, even this is wanting, and the sterile cyst is entirely filled with  a
clear, or semi-opaque, viscid humor. They are of very various size, from
a diameter of J to ^o of a  millimetre, the  former immediately preceding
vesicles distinctly cognizable with the naked eye. Conjointly with these,
are found cysts, which, with similar contents  and parietes, consisting of
a structureless transparent membrane, reside in an equally structureless
stroma, interspersed with  oval  nuclei,  and in progress of development
into a  fibrillation about to  encircle the cyst.
  We   further discern, commonly within an  aggregate  of spherical,
nucleus-like bodies, growths of various  magnitude,  down  to  that which
only just surpasses the dimensions of the nucleus.   These growths quite
coincide with  the aforesaid structureless vesicles.   The smallest  contain
a clear moisture, or are faintly  granular.   In the larger  ones, a central
nucleus soon appears, joined by a second, a third, a fourth, and more,
so as to fill  the equably dilated  vesicle.   This description  comprises the
history of the development of  the cyst, and may,  under  favorable cir-
cumstances, be found exemplified in a single preparation.  It is obviously
the nucleus that grows  up  into  the  cyst;  which,  with reference to
endogenous production, either  generates  brood nuclei or  else proves
sterile.
  Besides the nuclei, there are  seen smaller corpuscles of all sizes,  from
that  of the nucleus down to that of the so-called elementary granule,
and manifesting, in proportion to their magnitude, more  and more of
the character of the nucleus.  It is, therefore, at once to  be stated, that
the nucleus has arisen out of the elementary granule ; and this, through
spontaneous germination,—not through the  agglomeration of several. 
CYST.
173
Finally, we observe, in the preparation, concentrically stratified bodies,
also, of different sizes, and consisting of incapsuled  vesicles in varying
number.  These vesicles  are themselves sterile, or the  central vesicle
may have its space occupied  by one or  more granulated  nuclei.  Some-
times it is itself represented by a nucleus.   One or more  of the external
layers  contain,  in like manner, nuclei, oval in shape,  and bent to a
parallel with the layer.   Again, the  layers  are  in  some cases slightly
gibbous.  Incrustations of these forms  are  also present,—nay, kidneys
sometimes  occur, in which the cortical substance, otherwise seemingly
sound, is interspersed  with  them,  looking  like  yellowish, transparent
grains of sand.
   These are the results to which I  have referred, in describing the com-
pound cystoid.  A similar result is  furnished by the inspection  of a
group of cysts in the above-mentioned  sexual  attachments of the peri-
toneum.
   2. The renal preparation at first sight so much resembles the  texture
of the  thyroid gland, and more particularly the goitred  thyroid gland,
as to render it impossible to  discriminate between the two.   Simon has
directed attention to this  in vol. xxx. of the ' Transactions of the Medical
and Chirurgical Society.'  Not only is the  normal gland-vesicle of the
thyroid gland identical with  a cyst of corresponding size, but the de-
velopment of new gland-vesicles in a goitre is identical with cyst develop-
ment, and  again the preternatural dilatation of the  gland-vesicle—its
so-called  cyst-like degeneration—identical  with a cyst  outgrowing its
microscopical proportions. Nay, the gland-vesicle betrays in its develop-
ment the same  anomalies as the cyst in its development as a sterile
vesicle, or as a laminated cyst in its degeneration to a  colloid  sphere,
and in its incrustation.
   3. The same relations attach to cyst-formation in mucous membranes.
In those of the stomach, the  colon,  the  uterus, a morbid  growth  occurs,
known by the term cell- or vesicle-polypus.   It consists of  an aggrega-
tion of from  millet or hemp-seed  to pea-sized cysts, broad-based, but
mostly furnished with a neck, and commonly representing the  head-like
free extremity of a cylindrical prolongation of the mucous membrane.
These  cysts are developed  in  the  texture  of the mucous membrane,
seldom exceed the aforesaid volume, but burst and evacuate their viscid,
jelly-like contents upon the  surface of the  mucous membrane.   Their
fate, beyond this disruption and violence, I  have  been unable  to ascer-
tain.   They probably give place to new ones.   We may refer here to
those bodies suspended  by a pedicle of mucous membrane from the cervix
uteri, and known as ovula Nabothi.  These, though commonly received
within  the domain of physiology, in reality  present a continuous cyst-
formation, destroyed from time to  time by  disruption and  evacuation.
They occur, in like manner, on the mucous membrane of the renal pelves,
and of the ureters.
   But  I have repeatedly observed millet, hemp, nay almost  pea-sized
cysts, in surpassing numbers  in the mucous  membrane of these urinary
conduits.   Some of them  contained a flaky, inspissated, colloid moisture.
In one instance, my attention was  drawn to them,  by the presence of
little, roundish, naked, colloid pellets, in the urinary bladder. 
174
CYST.
  Just as in physiological textures, so also in pathological parenchymata
does cyst-formation  occur.   For example; in the textures of sarcoma
and carcinoma,—giving rise to the family of  cysto-sarcomata and cysto-
carcinomata.  Even the so-called carcinoma  alveolare consists,  mainly,
in cyst-development.
   Cancer-cyst varies in respect to size from the  microscopic, to  the  cir-
cumference of the colossal cysts, in the compound cystoid.  The alveoli
of areolar cancer in  particular—that is, the small  cysts  constituting
alveolar-cancer,—and  especially  the  peripheral-alveoli,  grow into com-
prehensive  cysts.   The cancer-cyst  contains a sero-albuminous fluid, a
jelly-like (colloid) substance, and frequently  cancer-parenchyma.   It is
not a rare thing to find—imbedded in a cancer, or independent,  and
remote from a heterologous growth,  ascertained by its volume to be the
primary seat of the cancer-production—tumors,  obviously consisting of
encysted-cancer parenchyma,  or cancer-tubera,  which, manifestly en-
veloped in  an  often stoutish fibrous capsule,  are distinguishable  at a
glance from other uninvested accumulations of the cancerous substance.
Within the encysted parenchyma, again, is sometimes lodged a  smaller,
filial cyst.                                   ■
   Upon this point and upon the development of the  cancer-cyst micro-
scopic inspection  throws  much  light.   The appropriate materials for
examination are afforded  more especially  by  cancer-masses, which, with
or without the presence of voluminous cysts, exhibit to  the unassisted
eye, minute, limpid vesicles, or else  an aciniform, glandular  structure.
   In such cancer-growths,  besides the ordinary  nucleated  cells, often
indeed distinguished by their eccentric forms, we discern:
   1.  Cells  of notable diameter, up  to ^th of a millimetre, with a very
large nucleus, dilated  into a clear vesicle,  which approximates to, if not
touches, the cell-wall.   In some of  these  bloated nuclei,  a  nucleus  cor-
puscle has become developed into a second central nucleus, which, in its
turn also, contains nucleus-corpuscle.
   In certain cells we  find two of these advanced  globular  or mutually
flattened nuclei, as also several  without a  nucleus-corpuscle, or with one
which, in like manner, expands  into a nucleus.   Other  cells  contain,
along with a swollen nucleus, one or more ordinary granulated or trans-
parent, spherical or  oblong  nuclei, besides.
   2.  Divested nuclei,  which, like the cell-included nucleus (cell-nucleus),
expand into larger, transparent,  structureless vesicles.  These—
   (a.) Remain sterile  cysts.
   (b.) They give birth to numerous secondary  nuclei,  until the cyst is
replete with these.  Such cysts often entirely resemble the gland-cyst of
the thyroid and supra-renal  glands.   Of these secondary nuclei, one or
more occasionally grow into a vesicle, which remains sterile, or fills with
brood-nuclei, or presents  phenomena about to be described.
   (c.) A central nucleus-corpuscle  appears in the vesicle and expands
into a secondary nucleus.—This nucleus,  like the primitive one, dilates
into a vesicle in  which a  nucleus formation of the third  order takes
place.
   Out of the frequent repetition of this process originate growths  con-
centrically  laminated, or  consisting  of a  series of endogenous  vesicles, 
CYST.
175
which here again are distinguished by their  proclivity to incrustation.
Sometimes there are developed, in one of the  secondary vesicles, more
than a single nucleus—for example, two out of each, out of one only of
which a laminated formation may become developed.   In the latter case,
ordinary brood-nuclei are generated  in the  other.   The inner vesicle
either remains  sterile, or a central nucleus, or it may be several nuclei,
engross its space.  Here,  again, there may be laminated  structures,
springing from extra-centrical nuclei.
   All these structures are lodged within a parenchyma (differing in com-
position, and in the fecundity of its elements),  of nuclei,  cells, caudate-
cells, fibres.   These elements  are so arranged as to inclose  the  said
structures in a capsular fashion, the cells, and even the nuclei, lengthen-
ing into riband-like, caudate cells, and oblong nuclei, with a correspond-
ing incurvation.   (Alveolar textural arrangement.)
   Still, the main  condition for  the growth of the vesicle is the presence
of encircling fibres,  and  their appropriation  to the fabric of  a resisting
fibrous cyst.
   The simultaneous evolution of the  brood-nuclei of  the  vesicle causes
the cyst to become speedily furnished with  a  proper parenchyma cor-
responding with that which  surrounds  the cyst.   In this a filial  cyst may
become developed.
   The structureless vesicles alluded to offer  many further points of in-
terest :
   (a.) There is, frequently, a marked difference in the contents both of
the simple vesicles, and of  the  individual layers of  the  vesicles succes-
sively ingenerated.   Thus,  some appear clear and colorless,  others of a
reddish tint; in others again, the contents are denser, pearly, or opaque,
lightly granular.  Some contain granules in various amount, which show
themselves to be fat,—fatty conversion of the nuclei.
   (b.) Of two intussuscepted vesicles  the inner one is sometimes irregu-
larly collapsed, wrinkled, or even pretty regularly indented.    This pro-
bably results from a consecutive difference of density in the  contents of
the two, a condensation of the  contents of the  outer vesicle determining
exosmotic effusion of the  thinner contents of the inner vesicle.
   (c.)  Intussuscepted vesicles are, for the most part, sterile.  Within
their layers, however, are frequently impacted  oblong, curved nuclei.
   (d.) The layers are commonly smooth ; often, however, gibbous, wavy,
and curled.
   The development of these cysts out of the nucleus, through growth of
the latter, is here demonstrable even  in the  naked  nucleus; by growth
of the  celled nucleus, however, it is  placed beyond  all doubt.  Here
again, the elementary granule is cognizable,  as the ultimate, funda-
mental  form;  the  nucleus  being obviously  and simply developed  by
growth out of the so-called  nucleolus,  or elementary granule.
   Difficulties might, however,  still arise so long as  that theory of cell-
formation  obtains which assigns to  the  cell  a genesis and an import
distinct from those of the nucleus.   If there be parent cells, their resem-
blance with the expanding  nuclei, both in form, and  often in their rela-
tion to chemical agency,  might render it no  easy task to determine the
precise  nature  of a vesicle, seeing that parent cells and parent nuclei are 
176
CYST.
met with concurrently.  In a laminated structure, it would be peculiarly
puzzling to  have to  decide, whether  its external contour belonged to a
cell, or to a nucleus-wall.
   From what has been  stated, however, the existence of  a cancer-cyst
certainly may be inferred, a cyst, namely, developed out of the elements
constituting  cancerous substance, and  productive  of cancer elements
within  itself.  Not every  cyst,  however, concurrent with   cancer, is
necessarily of a cancerous nature, the  malignant growth very possibly
wearing but  the character of an accidental complication.
   In  cysto-sarcoma  the  same relations  obtain as to the  [primitive] de-
velopment of the cyst.
   /9.  As regards the excrescences occurring upon the inner  surface of
the cyst, repeated observations have established the following facts:
   1.  Upon mucous membranes, and  especially upon that of the urinary
bladder, there occurs a cancerous  growth which we have  elsewhere
termed villous cancer, as a structure  pertaining to medullary carcinoma,
and containing within a  villo-membranous vascularized stroma, a medul-
lary (encephaloid) cancer juice.  Later investigations  have led to results
which induce me to reopen this subject.
   It consists, as a walnut- or a fist-sized tumor, of a multitude of densely
thronged excrescences, which, upon a cord-like, longer or shorter, pedicle
unfold  into  delicate membranes, breaking  up into numerous ramifica-
tions, and again  into more  and more tender branchlets, wholly overlaid
with  delicate villi.   Many twigs have  a grape-clustered appearance,
their  villi bearing poppy or  millet-seed-like, clear  or  opaque,  white
vesicles.  Larger cysts reside in the primary cotyledon and ramification.
Many excrescences, again, represent hollow, shut, or at  their free  ex-
tremity, wide-mouthed pouches.  In one instance, the entire growth
consisted of polyedrical,  at  their free  ends  for the most  part  wide-
mouthed, pouches, densely beset  with villi at the brink of the aperture.
The tumor is throughout surcharged with a  whitish, creamy, medullary
juice.   It is  frequently a more consistent  medulla-like mass that fills up
the cavities   of the  growth, which in  this  case acquires considerable
density, and offers proportionate  resistance.
   The growth is in general  highly  vascular, and  in its  recent  state,
turgid, of a deep purple tint, and prone to  hemorrhage.   At the base,
from  whence the tumor  commonly rises with a neck,  we  have  found an
extensive sinus of a venous kind, upon  the  inner surface  of which are
seen  numerous  pin-puncture  and poppy-seed-sized orifices,  leading  to
bloodvessels, which ascend within the pedicles of the excrescences, and
accompany their ramifications.
   In  the vicinity of, or  even remote from,  the  heterologous  structure,
are smaller groups, or solitary excrescences.  These,  when  young, are
very delicate, so  as when under water to resemble a fine nap.
   Microscopic  Examination.—In the cream-  or marrow-like juice that
exudes on gentle pressure, are found variously-shaped cells, with one or
several, in part turgid, vesicle-like nuclei, along with bare, middle-sized,
and larger-sized nuclei, furnished with a considerable nucleus-corpuscle, of
which one especially, was found  large, and presenting internally  a dull
secondary nucleus contour.  This juice resides in the before-mentioned 
CYST.
177
pouch-like chambers.  The excrescences are externally clothed with an
epithelial layer.
   The membranous structure constituting the excrescence appears as a
very delicate, transparent, structureless, here and  there  striated mem-
brane, overstrewn  with  oblong nuclei, and  breaking forth about  the
pedicle into slender wavy fibrils.   It  is invested  with  a simple layer
of  granulated nuclei for epithelium,  which  is,  however,  frequently
wanting.
   A clustered twig appears  as  a clavate, hollow structure upon a deli-
cately fibred pedicle, young cysts, as structureless vesicles, occupying
the interior of the protuberances.   Here are seen two outlines, of which
the outer one belongs to the protuberance, the inner one to the young
cyst;  elongated nuclei course  along between the two.  The cyst is re-
plete with spherical nucleolated nuclei.  A few cysts open towards the
pedicle of the terminal bulb in  which they are contained.
   In some of these sacculi are besides found, in various numbers up to
the point of repletion, fat-globules, some of  largish dimensions.   These
lend to the cyst the white opaque aspect already referred to.
   The larger millet-seed-sized vesicles,  visible to the naked eye, contain
a colorless, tenacious fluid in which the above-mentioned nuclei float.
   A morsel  of a  membranous  expansion  of the  excrescence appears,
when magnified by 50 diameters, distinctly to consist of two  layers,  and
is everywhere, but especially at the summit, overspread with numerous
bulb-shaped  protuberances, which themselves  throw out secondary pro-
jections ; whilst considerable bloodvessels ascend to all.   In the  inside
are here and there seated groups of fat-globules.
   Their  bilaminated structure renders it more than probable that  the
layers, in consequence  of the  copious  production  and accumulation of
the cancerous elements, separate into the pouches aforesaid, which, for
the same reason, give way at this free extremity.
   In 1842, a urinary bladder  was  shown  to us  by Hodgkin, at Guy's
Hospital, upon the inner surface of which were seated numerous largish
bulb-shaped cysts, filled with the excrescences referred to.
   The extensive development of the cysts in a mucous membrane is in
itself very remarkable; whether, with the excrescences, they  be of a
cancerous nature appears uncertain.   Upon the mucous membrane of
the renal pelvis we have  seen, along with young  cysts, some solitary,
others  grouped together  in  its parenchyma,  awl-shaped and bulbous,
smooth and villous, red, vascular excrescences.  They were seated, in
part singly, partly in collected groups, some bearing a just discernible
transparent globule at their free extremity, which microscopic examina-
tion showed to be a young cyst.
  2. Upon serous  membranes,  and the peritoneum in particular,  we
have, in  connection  with  luxuriating medullary cystocarcinoma of  the
ovaries, met with  medullary vegetations which, judging  from their  ap-
pearance and the arrangement  of their  vessels, would seem to belong to
this category.
  On the other hand, an examination of the preparations in the Patho-
logical Museum of Vienna has taught  us that the  dentritic vegetations
which often  luxuriate upon synovial membranes, and in the capsule of
  VOL. i.                          12 
178
CYST.
the knee-joint so numerously that it appears invested with them as with
a felt, really appertain to this class.   In the interior  of the hollow
growths which constitute them, a  development of areolar tissue takes
place, just as in the cysts of the vascular plexus, of which we shall here-
after  speak, until  they at length become  replete with  it.  The largish
terminal bulbs of their stems and branches are frequently so flattened as
to resemble linseed or melon seeds (Majo).
   The entire  excrescences with these numerously seated upon  them,
and it may be  in  imbricated order, acquire the aspect of foliage.   In
one instance we found  them to contain fat-cells, which  explains what
Johannes  Miiller meant by lipoma  arborescens.   In fine, we  doubt  not
that they offer the original nidus for the  production of  those circular,
smooth, or knotted, facetted cartilage or bone-plates, which occupy the
inner  surfaces  of  synovial sacs, often attain to a considerable volume,
and, by spontaneous detachment, become free bodies within the capsule.
   3. The encysted parenchyma is often contained free within the cyst
space ; sometimes, however, there is present a meshwork, issuing from
the inner wall  of  the cyst, the spaces of  which are filled  up with  the
medullary mass.   This framework consists of a transparent  striated
blastema,  pervaded by numerous spherical  and oblong nuclei, and break-
ing up into fibrils.  Simple hollow  bulbs shoot up from its trellises, and
into its chamberlets.   Respecting  the development of  this stroma, two
theories might be  propounded :
   (a.)  It  might result from a continuous separation of the internal layer
of the cyst-wall.
   (b.)  It  is, however, far  more probable that, like the framework of  al-
veolar gelatinous cancer, or of the encysted new growth of thyroid gland
parenchyma in goitre,  it  results from the blending of  the excrescences
concentrically growing  from the inner surface of the cyst.
   Occasionally, sharply-defined, spheroid cancer tumors occur in which
no cyst-wall is discoverable, but yet, in their interior, a stroma of this
kind.   It is very  probable that these tumors were  previously encysted
cancer-masses,  from  which the cyst has, owing to a total disruption with
excessive  production of those excrescences, disappeared or become part
and parcel of the stroma.
   The repeated examination of so-called alveolar cancer (gelatine cancer
in  alveolar  form)  offers very  interesting  results, corroborative  of the
endogenous multiplication of its  cysts.   Besides the  exogenous aug-
mentation, there  occurs likewise  an  endogenous one, the medium of
which is  offered by the often-mentioned excrescences ;  and in this pro-
cess these become  converted into the framework, in the alveoli of which
the small cysts are subsequently lodged.   From the  inner surface of a
thick-walled follicle, or alveolus, numerous simple bulbous pouches shoot
up into it, so as to penetrate it.  Another, contiguous,  is replete  with a
young delicate alveolar parenchyma.   In the interior of  those  hollow
bulbs is seen one,  or a pair of cysts.   In such  prolific cysts the develop-
ment of the fibre-layer for the young cysts may  often be seen proceed-
ing from  the base of the excrescences, near the inner wall of the  parent
follicle.   Gluge has seen these bulbous pouches in a cancer of the rec-
tum, and  figured  them.   Owing, however, to his  treatment of the pre- 
CYST.
179
paration, he recognized neither  their relation  to  the alveoli nor their
character in general.  He regards them as altered and hypertrophied
muciparous glands.
   Thus, encysted alveolar cancer is  accounted for and explained in the
same manner as medullary carcinoma.
   4.  Upon the  internal parietes of cysto-sarcomata there are known to
occur (in  the  so-called  cysto-sarcoma  proliferum)  warty,  foliaceous,
bulbous vegetations, as also pedunculate cysts.   The former often attain
to a considerable size, so as to fill up the space of the cyst, presenting a
flesh-like aspect.  [For  an explanation of these phenomena, the reader
is referred to an appendix to the separate section on cysto-sarcoma.~\
   5.  In goitre, besides others, there occur cysts filled with thyroid gland
parenchyma of accessory growth.   We have  often the  opportunity of
witnessing the process  of this endogenous production in its  incipient
stage.  From the inner parietes of the cyst arise  delicate, transparent,
protuberant, vascularized excrescences, in  the  interior of which a new
creation of gland-vesicles takes place.
   6.  Finally, in the domain of physiology, we encounter, upon the vas-
cular plexuses in the  lateral ventricles of the brain, a formation which,
as comparative microscopical investigations teach us, fully coincides with
the excrescences still  before us.  Upon  the lateral plexuses of vessels
are  seated great multitudes of delicate, red, vascularized villi.  These
consist, beneath  an epithelial covering, of  a transparent, multifariously
projecting, fretted, hollow growth,  in  the protuberances of which  run
arched bloodvessels of  no inconsiderable  size.  Here we seldom fail,
especially upon  subjects  advanced  in  years,  to  find numerous little
cystlets, for the most part lodged in those protuberances.  Generally
speaking they do not outgrow a certain  measure, a diameter  of from
g^th  of a millimetre up  to a cyst discernible by the  naked eye, and dif-
fering from what  are  usually called  cysts  of the vascular plexus.   By
dint  of  a repeated development of central  nuclei, the majority are
wrought into concentrically  laminated growths,  and undergo  incrus-
tation.
   The very common so-called cysts of the vascular plexus are not genuine
cysts.  Numerous examinations have convinced us of their being dilata-
tions of the hollow growth which constitutes the villus of the  bloodvessel
plexus.  This dilatation  pre-eminently affects  the villi adjacent to the
tortuous bloodvessels upon the convexity of the arch ^described by the
vascular plexus.   Accordingly, they are  clusters  of gibbous  and in-
dented vesicles, separated by the indentations into several loculi.  Little
remnants of villi  are  often to be detected upon them.   We have fre-
quently observed the dilatation of the villus at its commencement.  In
this  manner, the so-called cysts of the vascular plexus answer to the
pouches  into which the  excrescences constituting  villous  cancer widen.
Besides other matters, they contain areolar  tissue, sometimes to perfect
repletion, so that, in this respect, they may be likened  to  the excres-
cences upon the internal membrane of the cysts, and especially to those
which, through the development of areolar tissue, have become internally
parenchymatous ;  as, for instance, in the cyst of sarcoma.
  The contents of what are called cysts of the vascular plexus answer, in 
180                            CYST.
all essential points, to the contents of cysts proper.   They consist in a
watery  albuminous fluid, which, with a certain amount and  quality of
its  accompanying  organic elements, becomes turbid, thickish whey-
like, and  in great measure supplanted  by the development of areolar
tissue.
  These elements are—
  (a.) Minute,  sfo  millimetre-sized, elementary  granules, free, or  nu-
merously  held together by a viscid interstitial substance.
  (b.) Larger,  up to  nucleus-sized,  spheroid, occasionally  somewhat
oblong vesicles,  which speedily increase to ^gth of a millimetre.  There
are,  besides,  ordinary, granular,  spherical,  and oblong  nuclei  and
granules.
  (c.) The larger vesicles are simple, or  successively enshrined.  Some
exhibit a  double outline, that of the inner vesicle  often lying so close to
the outer  one  as to be easily  overlooked.   In other cases, the  two  are
widely parted,  the inner  one being slightly wrinkled  or  curled.  In
others,  again, there  is, between the two  contours, at some one spot, a
space defined  by a single outline, which sometimes resembles  a shallow
section of a sphere, and is particularly marked  where the compressed
contents of the external cyst are granular, and therefore contrast with
the limpid contents of the  inner vesicle.   In  some instances  the inner
vesicle is  small,  and either central to the outer one,  or resting upon its
wall.   The latter kind probably  engenders the form just adverted to.
  Other vesicles, again, consist of three or of four, the inner, secondary,
and tertiary  ones being by  turns central and  extra-centrical.  This
species  of complex and involved sheathing  is met with in very small
(asgth millimetre-sized) vesicles.  In some of the simple vesicles is found,
—in place of  a  wall-inclined, secondary, spherical vesicle,—an oblong,
wall-attached nucleus.
  (d.) With these are associated many-layered, smooth, or slightly  gib-
bous cysts, between the lamellae of which oblong nuclei are  often found
inserted.   The central vesicle occasionally holds a multitude of the most
various primary and secondary forms,—elementary granules (nucleoli);
spherical, oblong nuclei; simple and compound  vesicles, and incrusta-
tions  of vesicles.  These laminated growths, for the most part, undergo
an incrustation proceeding from the central layers.
  (e.) We also find the cysts of the vascular plexus to contain commonly
in the shape of a mucus-like substance, deposited, as it were, from  the
fluid, and mostly  infiltrated  with fine sand-granules, a  transparent
blastema  pervaded with round and  oblong nuclei.   This gradually forms
into  areolar  tissue, displaces  the moisture,  and  ultimately fills up the
entire space of the cyst, in the meshes of which the aforesaid forms all
lie  imbedded.   Within the structureless blastema we perceive the oblong
nuclei bent in accommodating  curves  around, and closely attached to,
the vesicles   (alveolar  textural  arrangement).   Such  cysts  gradually
shrivel around these their  contents, and finally become extinct.
  The aforesaid cysts are very delicate, commonly clear and transparent;
some refract  the light with a  whitish tone, their  contents  appearing
somewhat denser; in others, the contents are of a  reddish  shade; in 
CYST.
181
 others, again, finely granular, as though coagulated ; in others,  lastly,
 the contents consist of a multitude of sharply-defined granules.   To this
 class belong, more especially—
   (/.)  Globular bodies, in which the outline of a cyst-wall is wanting,
 and which represent lightly granulated spheres.
   (g.)  Lastly, the vascular plexus cysts often contain a whitish, chalky
 fluid.  This consists almost entirely of fat-globules, and gradually thickens
 into a lardaceo-cretaceous pap, around which the cyst speedily  shrivels,
 and perishes.
   The vesicles  and granulated spheres, the incrustations, the  areolar
 tissue developments and the  fat-globules, render  the  contents of the
 vascular plexus-cyst more or less opaque.
   y.  Finally,  we  have, in the well-founded  expectation  of throwing
 additional light upon cyst-development, examined their  fluid contents.
 For this purpose  we have  found the  contents of small (young) cysts,
 those, for example, which occur  upon the broad ligaments of the womb,
 or within the cortical substance of the kidney, especially serviceable.
 They  include a multiplicity of elementary  forms, essentially identical
 with what are observed in the vascular plexus cyst.   Nor is their occur-
 rence limited to the  cyst itself.
   The fluid, semi-fluid contents of the sac, consist in an albumen-holding
 humor, which possibly presents various phases,  the chief one being, how-
 ever,  that in  which it  constitutes  colloid.   In it  are  contained those
 elementary forms which are here fraught with  peculiar  interest.   It  is
 here adverted to irrespectively of what  was  before stated concerning its
 parenchymatous contents, as well as of whatsoever changes  hemorrhage
 or exudation may give rise to within the cyst.
   Besides the ddbris of an epithelial layer generally composed of granu-
 lated,  nucleolated nuclei, there are found:
   (a.) Similar free  nuclei, some holding two,  three, or four nucleoli,
 some visibly  exceeding the usual size of nuclei.   Along with  them here
 and there, a  form of which it is  problematic whether it be  a nucleated
 cell, or a full-grown nucleus, with a nucleolus.
   (b.)  Granules, the larger of which being  Ty-J-rjth  of  a millimetre in
 diameter, are obviously vesicles.
   (c.)  To both are associated vesicles  and cysts, which grow from the
 size of the aforesaid granules to ^$ih millimetre,  and as will be seen,
 beyond this.
   These cysts offer many points of interest:
   (a.)  They are  simple, or else  compound,  incased  within  and within.
 As regards the  latter, we meet in the  first place with simple vesicles,
 within which a central granule or nucleus-corpuscle has become developed.
 This progressively enlarges into a cyst,  in which the same  process may
 be repeated.   In a cyst are often contained two, three, four, and more
 secondary granules, nuclei, vesicles,  in which the process of ingeneration
 is still further repeated.
  (/5.)  Their  shape is commonly spherical, but often flattened by mutual
 compression.   Some, owing perhaps to the inspissation of their contents
are wrinkled, bent inwards, more or less  regularly indented.  This applies
to the simple cyst equally with the  compound, affecting in  the  case of 
182
CYST.
the latter all the involved cysts in various  degrees, or it may be only
one, and that the innermost.
   Some frequently throw out various projections, prolonged  into  cylin-
drical processes, which in turn display ulterior promontories, or it may
be inlets.  This applies both to the simple cyst, and also to the compound,
affecting all the layers in unison.   Occasionally, the  projections are
obviously determined by endogenous development out of multiplex nuclei
and vesicles.
   7. Their  contents present marked differences :
   The contents of simple  and compound  cysts  properly consist of a
viscid fluid, in some cases translucent and colorless, in others, of a reddish
tint.  In compound cysts,  these two conditions often alternate one with
the other.
   Some contain in and along with the said fluid, granules in various
numbers, even to thorough repletion; some, together with these, clear,
reddish-shaded vesicles, the size of a nucleus.  Others  contain  granu-
lated, spherical, oval nuclei.
   The fluid contents of certain cysts appear denser,  less transparent,
opalescent;  of others, still denser,  dully  transparent, presenting at the
same time a marked  cloudiness.  In  others,  again,  the  density  is still
further marked, and the cloud more sharply defined.
   This cloud results from a parting of the contents into spherical cor-
puscles, and flaky  pellets  of various size.   In a given cyst  it  seems
tolerably uniform, or else it consists in a radius-like Assuring from the
periphery towards the centre  of the cyst.   In compound  cysts, the sepa-
ration differs in degree and relative amount in the individual cysts, being
often more developed, either in the  outer or in the inner cysts, and in one
or other not present at all.
   The Assuring presents much that merits attention.  In simple vesicles
or cysts, it extends  from  the periphery towards  the centre, where the
radii or the points of the wedges of substance, bordered  by the fissures,
converge.   In compound  cysts, a fissure present in the external vesicle,
borders either upon the contour of a nucleolus,  of a nucleus, or  of the
secondary cyst, in  which, if there be a Assuring, it  is independently
constituted.   Or again,  the  fissure-lines of the  cysts correspond with
one another—in other words, the  fissure affecting  the external  cyst  is
prolonged  through  the  second,  third, fourth  inner cysts, &c, with a
radius common to all.  This is rendered  possible by the  metamorphoses
of the cyst-wall about to be explained.
   With the condensation of its contents, the wall of the cyst gradually
disappears,  seemingly blending  with the  contents to a uniform mass.
As in the case of the so-called cysts of  the  vascular plexus, the  entire
cyst is transformed into  a dull,  opalescent, resilient,  simple  or com-
pound, colloid globule, which splits under the covering  glass plate,—a
spherical, oval, cylindrical, or nodulated  colloid mass.  To this cate-
gory, doubtless belong the unexplained bodies seen by Kohlrausch in a
renal cyst.   (Vogel, Path.  Anat.)
   This relation of the cyst-wall further determines the contents, reduced,
after the completed process  of separation, to  an aggregate of stellate
flocculi, which break up into  roundish, opalescent fragments of  various 
CYST.
183
size.  There are always  present  globular ddbris from  which numerous
fragments of this kind have become separated.
  This  relation of  the  cyst-wall  occasions the  breaking up  of the
already fissured contents,  either spontaneously, or from pressure, into
stratiform, or wedge-like fragments, as is  particularly frequent in in-
crusted specimens.   The  same  cause produces the linear disruption,
through pressure of the  smooth compound colloid sphere, athwart many
of its strata.  These formations, together with the remaining amorphous
colloid contents of the  cyst, are sometimes  tinged of  a brownish  or of
a yellow hue, from imbibed pigment.
  An ulterior change in these formations, which should here be noticed,
is  their  incrustation  with phosphate  and carbonate of lime.   It  com-
monly affects the  compound laminated  cysts, but not unfrequently, the
simple ones  also; the comprehensive, equally with the small ones; the
smooth, equally with the gibbous.  It  invariably emanates in the simple
cysts from the centre, in the compound,  from the central layer, whether
this consist  of a  simple  nucleus, or a  group of nuclei in a  vesicular
nucleus-development.  The secondary cysts  lying  side by  side within a
simple or  a compound  cyst, become  incrusted independently of each
other, and also of the parent cyst.  The cysts affected with incrustation
are  those whose  contents  have undergone the  condensation before
referred to.
   Lastly, many cysts contain granules and globules, which are shown
to be of a fatty nature, the cyst resembling in some sort a colossal gra-
nule-cell.
   (d.) There is in the  primary and  secondary formations within the
cysts hitherto spoken of, frequently a colorless  hyaline, or colored col-
loid substance, in the shape  of roundish,  oval, facetted, poppy-seed,
millet-seed, or lentil-sized pellets  and flakes, and of larger misshapen
masses.   It is uniform in character with the opalescent, self-separating
contents of the aforesaid microscopic cysts.
   The presence of all  the semi-transparent  and opaque formations
renders the  cyst-contents  whitish, or  turbidly yellow.   This portion of
the cyst's contents is frequently separated in the form  of a deposit.
   With this I conclude  the  catalogue of facts,  relating to the cyst.  I
shall now  proceed to recapitulate  these facts,  and endeavor to  elicit
from them such deductions as they appear to warrant  and uphold.
   1.  The cyst is, with respect to its organization and secretory function,
an  independent hollow  growth,  essentially based upon  a substantive
element.
   2.  At the characteristic turning-point, between a primary (embryonic),
and a secondary  phase,  overstepping  the  microscopic scale, the  cyst
consists of a  structureless vesicle of from ^gth to y0th of a millimetre
in diameter, and an encircling  fibrous layer, maintaining various grades
of development.   To these is added, as endogenous production, a nucleus
or  cell-formation, limited to an epithelial stamp.  The cyst here com-
pletely resembles the glandular vesicle of the thyroid  gland, and  of
the  supra-renal capsules.   The  encircling fibrous layer  furnishes the
alveolus for the reception of the structureless cyst.
   3.  The  elementary germ of  the structureless  vesicle, resides in the 
184
CYST.
nucleus,—nay, inasmuch as the nucleus is obviously generated out of an
elementary granule, it resides in the elementary granule itself.   The
latter  grows  by intussusception into the nucleus, and  the  nucleus at
once  in  the same  wise  into the structureless  vesicle.    The  nucleus
arising out of the elementary granule either  retains the character of the
latter, as a smooth,  polished, sharply-pencilled vesicle, or acquires  the
well-known granulated character.   It  is  obviously the  former, in par-
ticular, that becomes developed into the structureless  cyst, even  the
granulated nucleus,  however, enters upon this  development, its contents
clearing  up during the process, but  resuming the  granulated character
afterwards.
   This history of cyst-development is essentially corroborated by  the
expansion  of the cell-nuclei, of so frequent, although  by no  means
exclusive,  occurrence in  cancer-cells;  an expansion  first pointed  out
with precision by Virchow, but which, owing to the identity of develop-
ment of  the normal  gland vesicle, and of the cyst, cannot be regarded
as heteroplastic.  It consists in the  development of the cell-nucleus into
a  comprehensive cyst, identical with that  evolved out  of  the  naked
nucleus.
   This corroboration is rendered  complete by the fact, that, in  the
inflated  cell-nucleus, an  elementary granule present as a nucleolus,
expands  into a nucleus, generates within  itself another neucleolus, and
forthwith becomes a second cyst.  This in my opinion affords important
evidence  of the vesicular nature of the nucleus, and of its evolution  out
of the elementary granule,  through  simple intussusception-growth which
Reinhardt  has shown to  be a property of the chyle-, the lymph-, and
the pus-corpuscles.   (See  Virchow's Arehiv., vol. 1, fas.  3.)
   4. To  the  cyst in its  primitive  condition, as  a structureless  cyst,
there accedes from  without, and blends with it, a more or less marked
fibrous texture.  The cyst  in this secondary  condition,  consists of a wall
of a  definite  texture, with an  internal  lining of epithelium, and  is at
once endowed with an enormous capacity of  growth.
   The structureless  cyst  is developed in a consolidated, structureless
blastema, commonly studded with spherical and oblong  nuclei, or else
in a nidus of caudate and  other cells.   In the former case,  the cyst is
speedily  surrounded with a  fibrous formation following the course of  the
encircling  oblong  nuclei, the cells  contiguous to the cyst assuming an
elongated,  ribbon-like, caudate shape,  and  arraying  themselves in
parallel  order around it.   A remarkable tendency to enter upon this
relation to  the cyst  is shown by the caudate  cells, which constitute so
many cancerous tumors.   They first associate  themselves one by one to
very small, young, vesicles, and shortly overlay them in quite dispro-
portionate numbers.   Even  oblong nuclei will fasten upon young vesicles
of the kind.
   5. This  arrangement of the elements of a texture, brought about by
the presence of young cysts, and consisting in  an essential portion of
those elements uniting to form capsules, and alveoli for the reception of
the cysts, I have termed  alveolar textural arrangement, or the alveolar
textural type, and assigned  to it a range extending far beyond the limits
of a special heterologous  formation.   This establishes  the  distinction 
CYST.
185
 between the alveolar textural arrangement and many similar, but diffe-
 rently engendered, meshworks, cavernous structures, and the like.
   6.  The cyst, in its primitive state as a structureless, vesicle, and also
 in its development, fully corresponds with  the simple gland vesicle—for
 example, the thyroid gland, and its development, as seen more especially
 in  hypertrophy  of  the thyroid  gland.  Nay, the same anomalies of
 development,  consisting in  arrest and  involution, are common to  both.
 On the  other side,  the  insensible progress  of the  gland-vesicle,  when
 imbedded in its fibrous alveolus, from its normal standard to the morbid
 condition of a cyst,  constitutes a process completely one with the secon-
 dary stage of cyst development.
   7.  Cysts form  singly, or else collectively, in greater, often in redun-
 dant number.  New cysts often arise within the fibrous wall of a parent
 cyst.   There  occurs also an endogenous multiplication of the  cysts, new
 ones being developed in the fluid or parenchymatous  contents of a cyst.
 In the former case, they do not in their development  overstep  the pri-
 mitive condition, for lack of the adventitious element requisite to con-
 solidate  and advance the structureless vesicle into the true cyst.
   8.  The  cyst, as  appears under the  circumstances discussed in § 6,
 possesses, under  the same form, a different import.   This it reveals more
 especially in  the character of the textural  elements frequently engen-
 dered upon its internal wall  through  the medium of the excrescences.
 These  repeat, now a  normal,  now a heterologous  parenchyma—for
 example, that of carcinoma.   We  are here reminded of  Hodgskin's
 idea, which has, from time to  time, been much too inconsiderately and
 hastily condemned.
   9.  Cysts are for the most part abiding growths, which often attain to
 a monstrous circumference.   There  are, however, cysts which never, or
 very rarely, exceed a certain volume, about  that of a grain of millet, or
 of  a pea, at which point they  burst, void their glassy, mucoid, colloid
 contents, perish, and are substituted by fresh ones.  Exploding cysts,
 to which belong the  cysts constituting the so-called vesicular polypi, the
 ovula Nabothi.   The cyst in its primitive state as a structureless vesicle
 appears  to burst, in like manner, and  eject the brood elements it con-
 tained.  At all events, open vesicles now and then occur which do not
 appear to have become  so by external means.
   10.  On the inner surface of the  cysts are found simple,  bulbous or
 dendritic excrescences,  which represent a bulb-shaped, pouch-like,  or a
 variously projecting, hollow-growth, branching out into  secondary and
 tertiary pouches,  and consisting in  a hyaline,  structureless membrane,
 studded with spherical and oval nuclei.
   These bodies shoot from the inner surface  of the larger cysts, isolated
 or collected in groups, sometimes from the innermost, sometimes, naked,
 from a deeper layer, and through slight fissures, or more spacious  gaps,
 formed by the cyst-wall giving  way.   Or, coming  from the deeper
 layer, they raise the internal structureless or striated lamina of the cyst-
wall into  a vesicle,  which  they afterwards  perforate,  and  with which
they coalesce, becoming blended  together with them into a meshwork.
In the  smaller cysts  they raise up the epithelium, and retain it as an in-
vestment. 
186
CYST.
  They contain an albuminous fluid, or one possessing the germs both of
physiological texture,  and of heterologous parenchyma.   Through its
accumulation they become changed into  protuberant or pouch-like sacs,
which last are often patent at their free extremities.   There is often de-
veloped within them a fibrous  texture which imparts  to them the cha-
racter of considerable, fleshy, shallow-lobed (condyloma-like) tumors, as
in the cyst of cysto-sarcoma; or they shrivel  into  fibroid  growths and
perish.  Above  all they  frequently engender, in the terminal bulbs of
their branches, young  cysts, thus  mediating the  endogenous production
of secondary cysts.
  They frequently enter  upon the final  transformation into a stroma of
fibrous texture, which  receives into a meshwork or into alveoli the ele-
ments of parenchymata of various kinds.
  They occur not only in cysts, but also upon serous and synovial mem-
branes, upon mucous membranes, growing, in all cases, into the respec-
tive cavities.  Their development frequently out of deep fissures in the
cyst-wall, renders it likely that they spring at some depth out  of hetero-
logous parenchymata, and ultimately penetrate into larger spaces formed
by the yielding of textures.
  They appear everywhere as germ-nidi, and as carriers of certain tex-
tural elements.   In the cyst itself their tendency is to fill  up space by
determining the production of physiological and pathological parenchy-
mata, but in particular the endogenous multiplication of the cyst itself.
In  the  vascular plexus,  and in the so-called Haversian  glands, they
occur as physiological  growths.   They have sometimes the  characters of
a benign,  sometimes of a malignant new  growth.
  The  correlation between the  chorion-villi and the  cyst-formation
occurring within  them  in the  shape of  acephalo-cystis  racemosa of
Laennec,  and between the  subject under discussion,  is hardly to be
doubted.  I have, however, failed, of  late, to obtain fresh  materials for
investigating this point.
  The cyst, in its primitive state, is subject to various anomalies produc-
tive of arrest of its  development,—of  involution  of the  sac.  These
anomalies consist essentially in  changes in the contents of the  young
cyst; it is therefore  desirable, in the first place,  to point out what is
most remarkable in the contents of the cyst generally.
  The first  and  most  marked phenomenon in point, is the presence of
delicate, diaphanous, for the most  part simple, but also nucleated vesi-
cles, the one kind including reddish glistening, the other kind, colorless
limpid contents.   In  growths consisting  of several  cysts,  encased one
within the other (expanded nuclei), it is common for one or the other to
include reddish  contents,  whilst the remainder exhibit a colorless,  clear,
or slightly opalescent  fluid.  Occasionally these  different contents alter-
nate several times.  These vesicles vary from  the size of a nucleolus, or
a nucleus, to that of a vesicle 55th of a millimetre  in diameter, or more.
The small ones occur  in  all physiological and pathological  fluids con-
taining plasma ;—in the blood, in the humor Morgagni, in exudates, in
the juice of  various heterologous growths, in the grayish blastema sup-
plying the  place of  atrophied nerve-medulla in  the brain and spinal 
C Y S T.
187
tube.  The larger ones occur more particularly in conjunction with cyst-
growths, and as forming part of the contents of cysts.
   The parietes of the vesicle, whatever may be the nature  of the con-
tents,  are uniform  with the sheath  of  the nucleus.   They resist the
influence of acetic acid, or  else the latter  occasions  thickening of the
membrane, and  a sharper  contour of the vesicle.  An examination of
the contents is essentially facilitated  by the following occurrence:  In
the above  summarily mentioned fluids, there probably is always, freely
suspended, a reddish glistening fluid  or viscid substance, both in little
globules, and in larger masses, moulded into various  forms, and, where
the current is impeded, divided into smaller  portions.   This substance is
rapidly dissolved by acetic acid.   It  forms the contents of nuclei, and
also of cells,—very commonly of cells the recipients of the brood-nuclei
of the thyroid gland vesicle, the brood-nuclei of young cysts,—some-
times the contents  of pus-cells, and  of  young cells  generally.  Here,
again, it is, together with the  very delicate cell-wall, soluble  in  acetic
acid.  In  like form Ave often observe,  especially in the contents of cysts,
a colorless, viscid substance, equally soluble in acetic acid, and probably
identical with the ordinary colorless cell-contents.
   These two  substances are, to  all appearance, unimportant  modifica-
tions of the same material.   Colorless elementary granules and nuclei,
after evaporation  of their  surrounding watery  medium, when placed
under the  influence  of liquor potassae, swell, and  assume a reddish tint;
we might,  therefore, fancy that a difference in density determined the
modification, the  reddish gleam being  simply due to a diminution of
density.
   The  colorless  (denser)  contents  are  coagulated by the  addition of
acetic acid, becoming still denser, bereft of transparency, opalescent.
   Akin to this change is that of conversion  into a colloid substance.
   Occasionally a fatty transition is suffered.
   Let us now proceed to pass in review those phases of the cyst, as a
structureless vesicle,  which we have set down as anomalies of its develop-
ment.
   (a.)  In the  first place, numerous cysts, like the brood-nuclei and cells
they frequently contain, break up, in  their primitive state, as structure-
less vesicles.  This is occasionally preceded by a dehiscence  and empty-
ing of the  vesicle.   In other cases, the contents  of the cyst  are first
converted into  fat, a transformation of the cyst to a growth resembling
the granule-cell.
   (b.)  Cysts developed within  a fluid [the fluid contents of  a cyst], for
lack of attachments,  and of certain textural elements accruing to the
structureless membrane from without,  do not overstep the primitive con-
dition.  They succumb to the processes of involution already described,
or enter upon  changes hereafter to be  explained.
  (c.) A remarkable arrest in the cyst's growth attaches  to  the endoge-
nous development of secondary and tertiary  vesicles,  resulting in  those
laminated  cyst-growths  destined  to undergo  early incrustation.   The
lamination may be  restricted to a system of many-sheathed  or encased
vesicles,  developed  out  of   either central  or extra-centrical, parietal
nuclei.  Or else several distinct laminated  systems occur within a com- 
188                            CYST.
mon peripheral one, several nuclei, simultaneously or independently de-
veloped within a secondary or tertiary vesicle, having  expanded into
vesicles, and these, again, generated  their own  proper central  or extra-
centrical nuclei.  This  explains the frequent deviations  from the sphe-
rical or oval forms.  The size of these growths varies greatly.   We may
have nuclei in which a  nucleus-corpuscle is  inflated to a vesicle  simply
bordering upon the contour of the nucleus, or, again, of ith of a milli-
metre in diameter.
  (d.)  Another  arrest  of the  development of a cyst, fraught with its
eventual destruction, consists in the conversion of its contents into colloid.
The cyst becomes reduced to a sheathless colloid mass, becomes fissured
or furrowed,  and so broken up into fragments.   In laminated vesicles,
this transformation may affect all the vesicles  uniformly or unequally,
often a single, and  that generally the central one, which, in this case,
generates no further nucleus, so that all ulterior lamination ceases.
  The consolidation to  colloid affects the contents, not alone of the cyst,
but also of its basis, the nucleus, and the elementary granule of nucleo-
lus.  This we observe alike where cysts  are involved in the said conver-
sion, and  also under  circumstances where  no cyst-development  takes
place beyond a  slight extra-normal  inflation  of the  nucleus.   Such
transformed elementary granules and nuclei  occur in medullary cancers.
  (e.) Next akin to colloid conversion  is the incrustation  of the cyst,
and of its bases (the nucleus and elementary  granule) with phosphate
and carbonate of lime.  It affects both simple and laminated cysts.  These
incrusted  growths vary from the bigness of  a nucleolus  and a nucleus,
to 5th, or even J of a millimetre in diameter.   They are, however, most
commonly of about ^gth to ^gih of a millimetre.   They are identical in
form with the simple and laminated cysts, namely, spherical, oval, smooth
or  nodulated,  lobulated, spindle-shaped,  or  cylindrical,  occasionally
hourglass-shaped, trefoil-shaped, facetted.
  On compression, they frequently split up into regular flaky or wedge-
like sphere sections, a circumstance connected, no doubt, with the capa-
bilities of  colloid substances to split  asunder according  to  determinate
radial  systems.   At other  times they break up into  smaller  roundish
stellae, or into wedge-shaped fragments.
  In laminated cysts   the  incrustation  is wont to commence with the
innermost layers, where the colloid consolidation of the  cyst's contents
begins.  From hence it  proceeds to the external layers.   Many incrusta-
tions are seen in which  the outer layer is  as yet free, the incrustation,
as seen from above, appearing  to surround it as with a light fringe.  In
vesicles with  several  collateral  filial vesicles,  the latter  become in-
crusted—beginning in  like manner  with  the inner  layer—whilst  the
parent cyst and its layers remain free for some  time longer.
  It occurs  originally  either  in  molecular  or in crystalline form, the
completed incrustations displaying, now a  stellate, now a crystalline,
stratiform aggregation.
  To sum up, it would appear that it is not the cell out of which the cyst
becomes developed, but the  nucleus, and that this latter again is evolved,
through endogenous growth, out of the nucleolus or elementary granule. 
SARCOMA  AND  CARCINOMA.
189
 Lastly, that the structureless cyst-wall is  not, as we once supposed, an
 independent textural development.

                    12. SARCOMA  AND  CARCINOMA.

   Kindred new growths, important  from their  frequency no  less than
 from the question arising, in every concrete case, as to their innocency
 or malignancy.  They constitute  an extensive  group, comprising  most
 of the  so-called heteroplases.  They occur, now  as independent tumors,
 which usurp the place of normal textures, now as throwing out a multi-
 plicity of roots or branches through the textures, interlacing with  their
 elements, destroying these, and  assimilating them to their  own  proper
 substance.
   Solidified, and more especially fluid blastemata enter very largely into
 their composition, both becoming developed after their own manner into
 the elements described under the heading, "Metamorphosis of Blastema."
 They become wrought  into a stroma, various in extent  and in design,
 which forms the receptacle for  fluid blastema and its elements.   Along
 with the fibrous stroma developed  out  of solidified  blastemata, massive
 fibrous textures, evolved out of cells and  nuclei, are derived also  from
 fluid blastemata.  Lastly, the structureless parietes of parent-cells, here
 so numerous, enter into an immediate fibrillation.
   The ulterior development of the parent-cell determines  that  very
 common texture, the alveolar,  as also the resemblance with  certain
 gland-textures ; for example, the salivary glands, the thyroid gland, the
 cortical substance of the kidneys, &c, resemblances which formerly and
 even recently gave rise to such designations as "  sarcoma pancreaticum,"
 &c.    When  these  heterologous formations  affect osseous structures,
 they often determine the extensive  new  growth of a texture simulating
 bone.
   Their chemical composition involves, besides the gluten of the fibrous
 elements, several other gluten-like  (pyin-like)  substances,  along  with
 albumen, casein, and fats.
   In size they vary from that  of a just cognizable new growth  to that
 of a human head, and upwards.
   In form they occur as  spherical, roundish, knotty, lobulated, stellate,
 irregular, ramified tumors.   The form of infiltration  belongs more espe-
 cially to cancers.
   Of consistency we meet  with every gradation, from  the fluid and
 gelatinous, to the consolidated, fibro-cartilaginous.
   Bloodvessels enter into the fabric of  all these new growths, although
 to a  very different  amount;  some  being, relatively to their  volume,
 sparingly vascularized, whilst others  are distinguished by their redun-
 dant vascularity.  In those of the latter kind, the collapse of the  blood-
 vessels after death occasions  a marked change in color, consistence, and
 volume.
   These tumors have a pathology of their  own, being  especially subject
 to hyperaemia,  hemorrhage, and inflammation  with its sequelae,  more
 especially ulceration and necrosis.
   Many undergo a process of involution and  extinction,  either sponta-
neous, or evoked by preliminary disease, especially by inflammation. 
190
SARCOMATA.
  They originate at all periods of extra-uterine life, and are occasionally
found of considerable size in the new-born infant.
  Upon the whole, no texture or organ is exempt from them.   There is,
however, something peculiar and remarkable in  the affinity  evinced by
certain types for particular organs.
  We would distinguish these new growths, as shadowed forth in the
heading,  into two series, the one comprising innocent, the other malig-
nant formations, for the grounds of which distinction we must refer the
reader to the section on " Organized New Growths."
  We have selected the term sarcoma to designate  the  benign growths,
not because  of any especial analogy with muscle-flesh, but in order to fix
and define a name familiarized by long  usage, and also by no little abuse.
The malignant we shall leave in possession of their ancient characteristic
appellation cancer,—carcinoma.
  To catalogue  the species  of  these  new  growths in a  strictly philo-
sophical order, is not feasible at this day.  We shall best respond to the
requirements of  practice by determining the species upon the grounds of
predominant structural and chemical relations, a due  regard being  had
to the general habitudes of a growth.   The varieties, numerous in the
instance of certain species, are for the most part concerned with elemen-
tary texture, by which the  general habitudes are not essentially in-
fluenced.

                            SARCOMATA.

  These, as already stated, represent benign new  growths.   They are
always purely local affections, and therefore exist almost always  as  a
solitary growth.  They are most commonly due to mechanical influences;
accordingly  their seat is generally in organs  or  parts near the  surface,
and obnoxious to such influences.  They are curable by complete extir-
pation ; that is they do not recur at the same spot,  and still less do they
multiply in other localities.
  They generally constitute circumscribed, spherical, stellate, and clavate,
superficially lobulated tumors.   Often  enough they ramify  throughout
the texture,  nestling and luxuriating through the elementary parts, so
that these perish, degenerating, so to say, into the heterologous growth.
  They often increase to a very considerable volume, and this within  a
brief period.
  They affect the areolar tissue,  the fibrous  membranes,—especially the
submucous,—the muscles, inter-muscular tissue, and submucous  muscu-
lar  textures (uterus), the bones  (osteo-sarcoma), particularly  the facial
bones,  glandular organs, the mammary, the parotid glands, even the
testicle;  and, in rare instances, the brain.
  The  osteo-sarcoma is often inclosed within a skeleton  sheath  formed
by the distended bone, which eventually becomes  perforated.   In rare
instances a new growth of bone enters, in the shape of an  inner skeleton
or framework, into its composition.
  Generally speaking, sarcomata are more frequent than carcinomata in
the early periods of life—those of childhood and of boyhood.
  They seldom lapse into a process of ichorous ulceration spontaneously, 
SARCOMATA.
191
although frequently through inflammation  brought on by the membra-
nous expansions which covered them, namely, the general integument or
the mucous  membrane, inflaming and sloughing away, so as to leave
them denuded.  This ichorous ulceration may even lead to cachexia and
exhaustion;  the inflammation itself,  however, never  gives  rise  to  a
specific infection,  and  to a multiplied production of the heterologous
growth.
   Sarcomata lend themselves  naturally to a division into three species.
   1.  Gelatinous Sarcoma.—A very  frequent heterologous formation,
of which there are several varieties.   It consists, besides some albumen,
almost wholly of a gluten-, chondrin-,  or pyin-like substance.
   The varieties are principally referable to consistence, which varies
from  that of gelatin to that of fibro-cartilage, conforming itself partly
to the amount of water held by the glutinous basement, partly to that of
the textural, and especially the fibrous elements developed within it.
   (a.) The first variety is a very soft, jelly-like, nearly limpid, tremu-
lous, yellowish-gray new growth, sparingly vascularized.  It is the gela-
tinous tumor—the  collonema  of Johannus Miiller.
   J.  Miiller describes the parenchyma of  collonema as made up of
spherules, some of which  are much larger  than blood-globules, inter-
spersed with crystalline needles.
   We have  met with  the gelatinous sarcoma in  different organs; more
commonly, however, in the brain,  and in the mammary gland, bearing,
if not all the  attributes of Miiller's collonema,  at least so close a re-
semblance to its texture  as to remove all doubt as  to their identity.
Our specimens presented, on the  one side, a perfectly embryonic  form
of collonema, on the other side one more highly  developed, and border-
ing upon the following varieties :
   A  roundish, goose-egg-sized, gelatinous tumor, from the  mammary
gland, consists of a very  soft, amorphous blastema, interspersed with,
for the most part, very minute elementary granules,  and delicate little
twig-like fibre rudiments.   This blastema is permeated by whitish mem-
branous  septa, differing from the basement  in  nothing save in their
greater consistency.
   A  very bulky, lobulated, gelatinous tumor  from the brain, displays
branched fibres, resembling the elastic, with very numerously imbedded
nucleated cells, mostly larger than the pus-cell.
   One extirpated along with a portion of the inferior maxilla,  exhibited
a stroma, consisting of elastic, branched fibres, shooting forth twig-like,
out of a stem.
   Lastly, a  fourth, from a spermatic cord, showed single spiral, elastic-
like, but  transparent fibres, in an otherwise  amorphous, tenacious  blas-
tema.
   (b.) The second variety comprises a series of kindred new growths,
marked by a progressively increasing density and resistance, and mostly
by a very pronounced stellate  and  lobulated structure.   A white, areolar
tissue-like fibrillation, cognizable with  the naked eye, and bearing in its
interstices nuclei and cells, caudate  nuclei and cells, and nucleus-fibres,
enters largely into its composition.
  There  is  here often both a  microscopical  and  also  a ruder alveolar 
192
SARCOMATA.
 texture and cyst-formation, which lend to the heterologous growths the
 semblance of a glandular  structure; the alveoli  and cysts being the
 especial holders of the gelatinous moisture.
   This variety of  sarcoma  is generally endowed with considerable vas-
 cularity.   During life, the  new growth exhibits various shades of red-
 ness, and offers to the feel either a woolly  resiliency or a greater degree
 of elastic firmness.  In the after-death collapse, it is of a grayish-red or
 reddish-white, flabby, and in various degrees resistant.
   (c.) The third  variety consists of  a firmish, amorphous  basement,
 broken up into solid fibres, after the manner of the intercellular sub-
 stance  of  hyaline cartilage, and teeming with cells more  or less re-
 sembling those of cartilage.   This variety approximates in its elementary
 structure to the cartilaginous  new growths, to the enchondroma, with
 which the gelatinous sarcoma is manifestly and essentially cognate.
   These varieties, more especially the last two, are often found com-
 bined in one and the same new growth.
   The  gelatinous  sarcoma, besides the rarer localities specified in the
 instance of collonema, namely, the brain and the mammary gland, affects
 the, parotis, the subcutaneous areolar tissue, the intermuscular parts, and
 with  great frequency the periosteum and  the bones, more especially of
 the face.   The  second variety is particularly marked by the immense
 circumference to  which the growth becomes developed, often within a
 brief space of time, through redundant lobulation and ramification.
   2.  The albumino-fibrous  tumor; fibrous sarcoma.—This tumor is of
 a fibrous texture, and is distinguished from  other and especially the pure,
 gluten-yielding fibroids, by  its albuminous  contingent.
   The  genesis of the fibres and their relation to the fluid albuminous
 blastema vary.
   (a.)^ The fibre-texture becomes developed out of  the fluid, that is the
 albuminous, blastema, according to the laws of the cell-theory.
   (b.) The fibrous texture originates out of consolidated blastema, form-
 ing in this case a stroma, in whose interstices the fluid blastema is con-
 tained and becomes developed.
   The fibre varies in all the forms derived from solid and fluid blastema.
 In particular, all  the forms described  under " Metamorphosis of Blas-
 tema," recur here  as  the stroma.  Again,  we have recognized in one  of
 the forms specified in the section on "Gluten-yielding  Fibroids," the
 transition from the latter  to fibrous sarcoma.
  Varieties of this sarcoma, dependent upon  the form and arrangement
 of the fibres, might, accordingly, be numerously adduced.  A frequent
 appearance in the albumino-fibrous sarcoma,  is the formation of the
 cystic and alveolar texture.
  Just as, in the gelatinous sarcoma it  is the gluten-like blastema,—so
it is a predominantly albuminous blastema with which the fibrous paren-
 chyma becomes drenched, or, with which the gaps of the fibrous stroma,
the cystic and alveolar spaces, become occupied.
  The albumino-fibrous tumor, like  the gelatinous sarcoma,  occurs in
areolar tissue, in the  periosteum, especially the submucous periosteum;
and in submucous and muscular strata of areolar tissue, as fibrous, pha-
ryngeal, nasal, uterine polypi, &c.  Moreover, it affects bones, especially 
CYSTO-SARCOMA.
193
those of the face, and, more rarely, glandular organs, the parotis, the
mammary  gland, the testicle.   It is spherical, elliptic, single, or more
often lobulated and ramified, more or less resilient, vascularized, turges-
cent new growth, with a texture fibrous to the naked eye.
   3.  The  albumen-like fibrous  tumor. (Johannes Miiller.)—The albu-
men-like sarcoma is a gibbous,  tenacious, albumen-like tumor, sparely
and but partially vascularized where its texture is slightly reddened and
less firm.   It consists, generally, of a white or yellowish-white, solid,
fragile mass.  Here and there it exhibits clefts or fissures, which con-
tain a synovia-like fluid.   It consists, in part, of  a uniform,  almost
structureless or indistinctly fibrous  mass.  According to Miiller, it is
made up of a basement of multifariously interwoven, microscopic fibres,
amongst which are interspersed a vast multitude of globules.  The tumor
is said to have yielded no gluten by boiling;  the scanty extracts to have
been  thrown down by the reagents of casein, and the  insoluble main
mass  to have represented an albuminous body.
   We have only once encountered this new growth, namely, in the bone,
within a loopholed, bony sheath.
   A  very interesting variety of sarcoma is the

                           CYSTO-SARCOMA.

   The combination of the heterologous parenchyma with cyst-formation,
the groundwork of which is here, as elsewhere, the  parent cyst and the
alveolus, together imparting to the new texture the glandular aspect.
   Just as the basis of the cyst in sarcoma is identical with that  of the
pure  cyst,  so, in like manner, do the  types of both simple  and compound
cyst-formation  here recur.   In point of fact, therefore, the forms de-
signated by Miiller as varieties of cysto-sarcoma, offer a mere repetition
of those types.
   These varieties are :
   1.  Cysto-sarcoma simplex.—The cysts imbedded in the parenchyma
of the sarcoma, are on their inner surface smooth, or simply speckled
with little,  isolated, injected elevations of parenchymatous texture.
   2.  Cysto-sarcoma proliferum.—In  the same parenchyma are found
numerous  intra-cystic  cysts, some flattened along, others attached by a
pedicle to, the parietes of the  parent-cyst.   With A. Cooper, we have
seen  some  of these secondary cysts  as hollow appendices, or even free
within the  parent cyst.  In  like manner parenchymatous masses of a
fibrous, or of an acino-glandular structure, grow as pedunculate offshoots
into the cavity of  the  parent cyst.   This offers a transition-link to the
following variety.
   3.  Cysto-sarcoma phyllodes.—A large  clavate tumor, consisting of a
firm mass,  and presenting a fibrous torn surface.   Within is one large
cavity, or  there are several cavities,  unprovided with any cognizable
proper membrane, into which firm, sarcomatous, red, vascularized, folia-
ceous, or warty, tufted, broad-based, or pedunculate,  bulb-shaped, some-
times cauliflower-like, or fringed and villous excrescences,  germinate and
grow.  These consist of the  same substance  as in the former  case, but
are mostly  less dense and more succulent, readily drawn out length-wise
  VOL. I.                           13 
194
CYSTO-SARCOMA.
into fibres, or spread out to a membrane, showing  that they exist in a
folded and rolled-up condition.  Along with  them the cavity contains a
viscid humor.
   In this description of the cysts in sarcoma, we  easily recognize the
types of pure cyst-formation.   Whatever  interest, however, attaches to
this repetition, its description is inconclusive as regards the real nature
of the new growths.  The main feature is still the  heterologous paren-
chyma, which beoomes  the cysto-sarcoma without doffing its primitive
character.   This parenchyma  is that of the gelatinous and albuminous
sarcoma.   A peculiarity, in point of form, consists in the membranous
basement of sarcoma phyllodes, in its above-described exquisite form.
Cysto-sarcomata, and the species  phyllodes most particularly, often at-
tain to a  very considerable magnitude.   They are frequent in  the
genital organs, of females more especially, in the mammary gland, in
the ovary, less often in the testicles.  In a word, they occur in all those
organs specified as liable to  the development of  sarcoma, in  its several
species.
                              APPENDIX.

   [Since the publication of Rokitansky's  treatise on cyst and on goitre,
he  has devoted much attention  to  the subject  of cysto-sarcoma, the
chronic mammary tumor of the late Sir A. Cooper, the imperfect hyper-
trophy  of  the  mammary gland  of Mr.  John Birkett, the  mammary
glandular tumor of Mr. Paget.   Rokitansky,  in an essay, read before
the Imperial Academy of Sciences,  at Vienna,  in Jan. 1853, on " The
new growths of the mammary gland  texture, and its  relation to cysto-
sarcoma,"  gives the details of several minute  examinations of these
tumors, the results of which are thus summed up  : " In the one  case are
found imbedded within a small transparent, succulent  tumor, acinus-like
formations, consisting of a  structureless membrane,  and replete  with
nuclei.   In the second  case are  found,  in  the  texture  of nodules, of
which  the tumor is composed, numerous delicate fissures  bordered by a
fringe, in which the matrix substance  is, with the naked  eye, seen to
shoot inwards, in the form of almond- or bulb-like  projections.  There
are also larger cavities  present, into which  stellate  masses project.  A
magnifying power  shows that these  projections  themselves begin to be-
come lobulated  at their  terminal  points.   In other cases an extreme,
lobulated, textural mass is thrown forward into a fibrous cyst;  some of
its lobes being again enveloped by a cyst.   Upon the surface of others
are found furrows, whose margins spring up into  conical and bulbous
excrescences, and, together with these, larger, open, cyst-like  chinks.
In the texture of those lobules are, moreover,  channels and acinus for-
mations, as also upon the  cut surface, chinklets cognizable with the
naked eye, which, under a magnifying power of 90 diameters, appear as
considerable cavities branching out in all directions, whilst between their
emissaries  the  neighboring  texture  shoots  inwardly in the shape of
conical and bulbous excrescences."
   It results from this that—
   1.  The acinus-like cavity with its emissaries  resides in  a layer con-
sisting partly of embryonic, partly of fibro-cellular tissue. 
APPENDIX.
195
   2.  The cavity enlarging, coalesces with the matrix substance, which
grows into its space in the shape  of conical and bulbous excrescences,
whilst these, at  their free extremity, throw out lesser projections.
   3.  As  these  multiply, the number  of the  fissure-like emissaries in-
creases.
   4.  They shoot out from all points  around the dilating hollow growth,
or from individual points, or from one  point only, into  the  excavation.
Where they are wanting, the dilatation of the cavity is  uniformly that
of a cyst  with smooth parietes.
   5.  This dilatation is often  very considerable, and the excrescences
may also  attain  to a vast size.
   6.  In these excrescences, a secondary formation of acinus-like growths
takes place, in which the events which  occurred in the primary one are
severally  repeated.   This  occasions  certain   excrescences to  appear
encysted whilst  others remain bare.
   7.  At the surface of the excrescences are observed furrows or open
cyst-like clefts,  into which excrescences intrude in like manner.
   Dissenting from the view to which Mr. Paget inclines, namely, that
these tumors originate as  cysts, subsequently lose  their  cyst form, and
continue  to  grow as  solid  masses, differing,  moreover, with  Mr. J.
Birkett, who attributes them to a blastema effused into the areolar tissue
of the mammary gland, Rokitansky contends that an acinus-like hollow
growth which  determines this tumor, and  repeats one  element of the
mammary gland, becomes developed within a matrix of new-formed con-
nective tissue, which primarily constitutes the tumor.   And this tumor
is by no  means encysted, unless  an adventitious  fascia-like  sheath of
areolar tissue be called a cyst.  A true cyst is only subsequently de-
veloped within it through the dilatation of the  said gland-structure, the
connective tissue layer  being expended  upon  the construction of the
fibrous cyst-wall.  This, growing into the space  of the cyst, and carrying
before it the  primitive   structureless  cyst-membrane,   works  out  an
encysted textural mass, an encysted tumor, in which the gland elements
are reproduced.
   The dendritic excrescences, therefore, which vegetate in the  cyst of
cysto-carcoma, are  not, in Rokitansky's opinion, and, as he  once  held,
outgrowths from the internal cyst-membrane, but intrusions into the cyst
of its own cradle mass, or matrix, still invested with the primitive cyst-
membrane and its epithelium.
   Cysto-sarcoma simplex, in which the cradle mass does not intrude at
all into the cavity of the cyst, is of the rarest occurrence.
   C. proliferum is engendered by the development, within  the terminal
excrescence-bulbs, of the acinus-like cavities into filial cysts, and the in-
growing of the cradle mass is here repeated.
   The cysto-sarcoma phyllodes of Johannes  Miiller, with its amply de-
veloped, warty,  cauliflower- and foliated- or  cock's-comb-like ingrowths,
has nothing to mark it beyond the size and development of the excre-
scences.   The cyst-membrane is here no longer demonstrable,  having
coalesced  with the cradle mass of the cyst.
  It has   been  stated  that the dendritic  intrusions into the cyst may
occur at one  point  only of the cyst, at several points,  or, lastly,  at all 
196                  CANCER — CARCINOMA.
   points simultaneously.  In  the  last case they converge,  coalesce, and
   eventually fill the entire cyst, determining thus its aggregate, lobulated
   structure.
      With two  exceptions,  the one  mentioned  by Johannes  Miiller, the
   other by Mr. Paget, of these tumors occurring in the breast of the male,
   Rokitansky knows them only as affecting the female breast, where they
   are generally seated at the inner and upper part of the mammary gland.
      Their figure approximates to  the  spherical.   Small tumors  are com-
   monly even and  smooth, greater ones irregularly nodulated, knobbed,
   lobulated, at the same time tolerably resistant, elastic, often generally
   or partially presenting the feel of a cyst tense with fluid.
      The skin often presents  a livid  aspect,  and is traversed by dilated
   veins.  It is sometimes found coherent with the tumor, but not degene-
   rated.   The mammary gland becomes displaced by large tumors, and
   wastes away.
      These tumors have  an enormous  capacity of enlargement, growing,
   now slowly, now  rapidly, often with  lengthened periods of  arrest.   Oc-
   casionally  they  disappear  spontaneously.   In a  few  instances several
   small tumors are concurrently present.
      They are usually painless ; there are cases, however, in which the pain
   is excessive.   These represent Cooper's irritable  tumor of the breast, a
   fibrous tumor (a neuroma) for the most  part associated with the present
   new growth.
      The individuals  affected  are often unwedded, or childless females.
   The married and child-bearing are however  not exempt.
      The tumors are innocent, and, although often recurrent at the same
   spot after extirpation (Mr. Birkett relates a case of their  reproduction
   five  times in succession), not  so beyond the range  of the mammary
   gland.  In many respects  they are  analogous to the fibrous tumor of
   the uterus, and to enchondroma.
      In rare instances they undergo ulceration, which involves the super-
   imposed cutaneous textures.]

                          /S.  CANCER—CARCINOMA.

      Heterologous growths not distinguishable from  sarcomata by definite
'   generic marks, and, like these, to be dealt with only as species, but con-
   trasting  with sarcomata in the  single  feature, common to them all, of
   malignancy. Carcinomata originate  and subsist not rarely  as local evils.
   Far more commonly,  however, they are associated with  a dyscrasis,
   which, in point of fact, often precedes and engenders the cancer. Hence
   the multiple appearance of carcinoma as the sequel to a  single one, as
   the sequel to the extirpation of a voluminous and  hitherto  solitary one.
   Hence, in  other cases, the original appearance of cancer in several
   organs simultaneously, or in rapid succession.
      Conformably herewith, carcinomata can rarely with adequate reason
   be attributed to external local causes, whilst it is very common for them
   to luxuriate in internal organs beyond  the  reach of  palpable  influence
   from without.
      The crasis which gives rise to the production of cancer, consists mainly 
CANCER — CARCINOMA.                  197
in a preponderance of albumen, a defibrination (hypinosis), for the par-
ticulars of which we must refer to the doctrine of crasis.  Concurrently
with this we have, more especially in the medullary crasis, an excess  of
fat in  the  circulating fluid, which determines  a complication  of  cancer
to be discussed in a more appropriate place; and, again, that remarkable
relation of exclusiveness towards ordinary, fibrinous tubercle.
   This crasis is essentially the same for all cancers, only exquisitely de-
veloped in the medullary form.   This may be inferred, at least, from the
frequent concurrence of various cancer species, in  primitive or consecu-
tive combination, either in the same locality, or in different  organs.   It
may also be inferred  from the circumstance that,  after extirpation, the
one is replaced  by  the other under  the same contingencies, and that,
conforming with an augmentation of the crasis, the medullary cancer  is
generally the consecutive one, more especially where  the  substitution
takes place rapidly.
   The highest grades of cancer-crasis originate through infection, that
is, through  the reception into the lymphatics, or  more especially into
the bloodvessels, of  cancer-cells, or of cancer-blastema, of  a  lax, soft,
semi-fluid character.   The  blastema  is  carried thither by imbibition,
partly in the mere act of nutrition, partly, with or without  the cancer-
cells, through the lymphatics or  veins  laid open  by ulceration  of the
tumor, or lastly, by the cancer penetrating into the canals  of bloodves-
sels.   Infection  thus  brought about,  occasions locally, or it may be
remotely, both in large bloodvessels and in the capillaries,  coagulations
of blood.  In the former case, these are cylindrical, branched, plug-like,
or clavate coagula, adhering to the internal bloodvessel membrane, or to
the endocardium (vegetations).  They reveal their  cancerous nature by
their external medullary characters, as well as by their vigorous growth.
In the capillaries the coagulation assumes  the form of the  cancerous
depot—so called metastasis  (capillary phlebitis).
   Cancer-formation  assumes  both a  chronic and  an acute course, the
former being the more ordinary mode of occurrence for primitive cancer;
whilst secondary cancer production is brought  about with more and more
rapidity in proportion as the cancers  multiply.   Ulceration and extirpa-
tion of carcinoma are especially apt to determine its very acute secondary
formation.   Still there are instances  of highly acute, primitive, general
cancer production.   Moreover, the individual species of cancer manifest
marked differences in this respect, both  the  first development and the
ulterior growth, for example, of fibrous cancer,  being slow, whilst in the
case of medullary cancer they are incomparably more rapid.
   In primitive cancers, the  blastema  is,  in the great majority, insensibly
produced.  In acute cancer-formation it is thrown  out under the  symp-
toms  of hyperaemia,  and occasionally of inflammation. In the latter
case, it often covers serous membranes with a stratiform cancer exudate,
or infiltrates  and hepatizes the  lungs  with cancerous tubercles.  From
what has  been said, our opinion may be inferred respecting the seat
of cancer, in opposition to that of Carswell  and Cruveilheir, who refer
its origin to  the  capillary system.  But, although in the ordinary pro-
cess of cancer-formation we look upon the blastema as an exudate in its
broadest  sense, we  by  no  means question  the origin  of  cancer from 
198
CANCEB.
coagulation within the bloodvessels after the type of depot-formation in
general (see Metastasis).  It is indeed to this mode of development that
we would ascribe the rapid cancer-formation engendered, in brutes,  by
the injection of cancer-blastema.
  We  are further disposed—although from  isolated  facts  only—to
believe in cancer-formation, through a conversion of certain physiological
elements into those of cancer.   In the liver, namely, we occasionally
light upon a process, limited to circumscribed patches, of pallescence and
alteration of the parenchyma, with some  augmentation  of its volume.
Upon further examination, the portion of  liver so affected is  found to
consist indubitably of hepatic cells, more or less bereft of their biliary
and coloring matter, and of an intermediate, whitish,  albuminous blas-
tema,—as though the hepatic cell had become transformed into the  cell
of medullary carcinoma.
  Cancers present  sometimes well-defined, easily removable, spherical,
irregularly knobbed, lobulated, branched tumors, which  may lose their
circumscribed character,  only during  their  progress, by  insinuating
themselves betwixt the elements  of  textures hitherto merely displaced.
Or they may appear, from the first,  as  infiltrated heterologous masses,
involving the textures without definite limits.  When an established can-
cerous mass stretches forth from one organ to seize upon a second,, the
latter is forcibly drawn  in the direction of the first. Membranous forma-
tions, in particular, become attached to it with umbilical flattening, waste
away, and become perforated by the heterologous mass.   This is espe-
cially the case with fibro-carcinoma.
  The  size  of carcinomata greatly varies.  As tumors, some, and in
particular the gelatinous and medullary forms, attain to a very considera-
ble magnitude.  A special notice is due to  the  occurrence of cancer in
the shape of little millet- or hemp-seed-sized tubercle-like granules, as
detected upon serous membranes.  They have the import of medullary
or of gelatinous cancer,—sometimes, however, of the alveoli, or follicles
of alveolar cancer.  In  membranous formations, the magnitude is often
represented in the superficial extension  of the mischief wrought by  the
infiltrated malignant matter,—as in cutaneous cancer,  in cancerous de-
generation of the dura mater,  &c.   The number of cancers present in an
individual differs materially, varying from the solitary tumor to almost
general cancer-production.
  With reference to the occurrence of cancer in the different organs, it
may be generally stated, that no organ or  texture,—not  even  cartilage
—is exempt from  it, with the solitary exception  of horny  textures.
Certain organs, however, are hardly ever primarily affected with cancer,
being attacked only, either  under the conditions of  general  cancer-pro-
duction, or through contiguity with, and by propagation from some other
organ previously a prey to the affection.  Thus, primitive cancer of the
salivary glands, or of  the  small intestine, very seldom  occurs, of the
lungs or of the spleen scarcely ever.
  As regards the preference of cancer for different organs, the following
average scale of frequency might be established.  First, the uterus, the
female breast, the stomach, the large intestine, and especially the rectum ;
next comes the cancer of lymphatic glands, especially as  retro-peritoneal 
CANCER.
199
cancer-accumulation in front of the vertebral column; hepatic, peritoneal
cancer ; bone-cancer; cancer of the skin, and of the lips;  of the brain; of
the globe of the eye ; of the testis ; of the ovary; of the kidneys; of the
tongue; of the oesophagus; of the salivary glands and parotis. Again we
meet occasionally with cancers in large serous sacs, as in the peritoneum, for
instance, adherent only by very inconsiderable portions of areolar tissue,
or vegetating at large, and sometimes attaining to an enormous  volume.
Bone-cancer has now and then a sheath-like skeleton; far more frequently,
however, it scatters the bony substance piecemeal, advancing at the same
time,  with redundant bone-formation,  in  the  shape  of a  laminated,
stellate, thorny stroma.
   Both in the primitive, and still more  in the secondary appearance of
cancers,  we  may,—apart  from  all disease from contiguity—discern
certain relations of sympathy ; for example, between uterus- and ovarium-
cancer, between testicle- and kidney-cancer, between stomach- and liver-
cancer, between stomach- and intestine-cancer;—cancer of the spleen is
probably always associated with liver-cancer.
   Generally speaking, cancer is  more common  in the middle  and  ad-
vanced periods  of  life.   This relates,  however, only to the cancer of
certain organs, more especially of the mammary glands, of the uterus,
of the stomach and intestines.  All other cancers, especially those of
the lymphatic  glands, of the brain, of the eyeball, of bone, &c, occur
even  in  early youth.  Of the individual forms, the medullary is that
most  common at the earlier periods  of life.  In rare instances it is met
with even in the foetus.
   Cancers are themselves subject to not a  few diseases, amongst others,
to hyperaemia with  intumescence, and  to  hemorrhage.  The most  im-
portant amongst them is,  however,  inflammation.  Besides this, they
are liable  to metamorphoses, inductive of  an involution of the  cancer;
and  these are developed, apart from external causes, in  due proportion
to the vascularity of the organ, and  to the looseness of its texture.
   Inflammation may become kindled spontaneously in the interior, the
depths, of the heterologous growth.   Or  it may  be the obvious conse-
quence of external influences,—of irritating medication ; of exposure of
the tumor, after perforation of the  investing external skin  or  mucous
membrane, to  contact with  the external air or  with passing secretions
and excretions.
   Its distinctive signs are identical with those which reveal the inflam-
mation of normal structures, and they are  developed in the direct ratio
of the vascularity and looseness of texture of the  heterologous  growth.
The disease has a  marked tendency to open up, and, by  hemorrhage
and its results,  to  destroy such texture.   It takes either an acute or a
chronic course.
   Its products are  sometimes organizable; more  frequently, however,
and  more  voluminously, they are coagulable, yellow,  fibrinous, or yel-
lowish-white albuminous, deliquescent, pus-like,  purulent, and ichorous,
—very often hemorrhagic—exudates.
   Its terminations,  besides discussion  of  the inflammatory stasis, and
resolution, are: 
200
CANCER.
   1. Abiding of the products in their primitive crude condition, or else
 disruption, wasting, textural conversion.
   We  have here, first, to advert to the textural conversion of consoli-
 dated fibrinous exudates, to  gluten-yielding fibroid textures which may
 spring  up as a reinforcement of similar stromata already in existence.
 Secondly, we  have  to mention the  development  of  embryonic  cancer
 elements out of  a fluid exudate, as represented in inflammatory hyper-
 trophy,—increase of volume of the new growth.   Both may concur with
 deliquescent, pus-like, ichorous exudates, and, emphatically, with genuine
 pus-exudate.
  ^ 2. Suppuration,  ichorous production,—the  most  ordinary  termina-
 tion.   It runs  either an acute or a chronic course, with or without simul-
 taneous granulations, possessing the  character of a  rapidly developed
 new  growth—representing certain lax,  bleeding,  easily  suppurating,
 sloughing, fungus-like vegetations upon the cancerous ulcer.   This pro-
 cess takes place  either in the depths  of the growth, in a shut space, as
 so-termed occult  cancer; or upon the free  surface of the body or of a
 mucous cavity, as so-called apert or open cancer.   This last is, for the
 most part, marked  by a funnel- or  crater-like, deeply-extending base,
 with an elevated, mammillated brink.
  _ Ichorous  destruction of a  cancer is very commonly followed by fugi-
 tive reproduction of the fungus upon the base of the ulcer, by the accu-
 mulation of cancerous matter in its vicinity, by cancerous  degeneration
 of  the  implicated lymphatic glands, and, lastly,  by the translation of
 cancer  to other organs.
   Even independently of suppuration, and without its concurrence, the
 necrosis of cancerous growths, both small and great, is not unfrequent.
   Ulcerating and necrosing cancer—cancer-ichor—besides its corroding
 property, is marked  by a very disgusting, penetrating fetor.   This is,
 no  doubt, essentially due to the sulphur and phosphorus of the broken-
 up  protein and fatty constituents of the tumor, especially when exposed
 to the air.
   We have  here  still to advert to one  other important phenomenon.  In
 cancers of  the most different structure—in all cancers—we meet, not
 rarely,  with  a  yellow substance, sometimes scattered in points, some-
 times permeating the texture as straightened  or serpentine,  ramified
 striae, interlaced  to form a mesh- or network, or, on the other hand, im-
 bedded in considerable masses.   It is a yellow, brittle, consistent,—or
 a soft, friable,  unctuous, glutinous substance, which, if closely examined,
 is found to  consist either of an  amorphous blastema, dotted here and
 there with minute molecules, and  interspersed  with  misshapen  nuclei
 and with more or fewer  of  the  elementary cells of cancer,__or else
 chiefly scattered  or  grouped  elementary granules  (or fat-molecules), of
 the elementary cells of cancer replete with the same elementary granules
 and lastly of fat-drops.                                             '
  This  substance constitutes, in  the aforesaid mesh- or network  the so-
 called reticulum  of Johannes Miiller, who, regarding it as essentially
prolific  of cancer-cells, founded upon  its presence a new species  under
 the denomination of cancer reticulatum.
  On this point  we  cannot quite agree with Johannes Muller,  the said 
CANCER.
201
reticulum not being confined to a  single species  of cancer, but occa-
sionally met with in every form of the disease.
  We hold it  to be, generally speaking, a solidified product of inflam-
mation  destined, earlier or later,  to  break  up, its protein-substances
along with the contained cancer-cells undergoing fatty conversion.   We
look upon this process as both interesting and important, inasmuch as,
from its original foyer in the said substance, it gradually evokes a simi-
lar  process  throughout the cancerous growth.   This is particularly the
case where  the  substance  possesses the  reticular form, so as to master
the cancerous parenchyma at all points.   It is certain, however, that the
cancer-blastema itself undergoes the very same transformation, and that
spontaneously.
  Cancers for  the  most part prove fatal, sooner or later, by their ex-
hausting effects.  The anaemia, emaciation, and eventual exhaustion are
the result of the luxurious growth of a single tumor, or of the develop-
ment of a multitude of smaller tumors, or of hemorrhage  or ulceration.
Moreover, cancer, like other heterologous growths, kills through mecha-
nical hindrance to the  function of vital organs which it may have made
its  abode—for example,  the brain.   Acute, violent  cancer-production
rapidly destroys life, through the prefatory and attendant hyperaemia of
important organs.   Suppurating cancers become deadly through infec-
tion of the blood, and pyaemia.
   However seldom the extirpation of cancer proves successful, its spon-
taneous cure is a still greater rarity.   So favorable a result  can only be
brought about either by the progressive destruction, necrosis, and partial
rejection of the tumor, or else by its more rapid death and expulsion; a
circumscribing suppuration isolating it from the healthy textures—(mam-
mary, uterine cancer).
  Other processes  of  cure present, however,  greater interest, bearing
the character of an involution, a decadency of the cancer.    Such are :
  1.  Saponification of cancer, a metamorphosis usually evoked by the
conversion before alluded to of the substance constituting the reticulum.
It partly consists in the liberation of fats, or in the conversion of protein
substances into fat,  with consecutive emulsive and saponaceous blending.
This process, the above designation of which is warranted by a series of
minute examinations, attaches chiefly to the encephaloid, medullary car-
cinoma, so remarkable for its proportion of fats and of mutable crude
albumen,  and occurs more especially in the liver and the womb.
  2.  Decadency, wasting of the tumor, with condensation, solidification
of its blastema, liberation of salts of lime in the shape of free molecule,
and cell-incrustation.  It affects in particular the denser cancers pro-
vided with a solid blastema  (intercellular  substance),—the firmer medul-
lary and the fibrous cancers.  The ossification  and  cretefaction of  in-
flammatory products in cancer often  gives the first impulse  to  this.
Here again ossification and cretefaction (of the reticulum)  are combined
with fatty conversion.
  Although carcinomata  are, generally speaking,  pre-eminently malig-
nant  new growths,  still the degree of  their malignancy is not  the same
in all, medullary carcinoma occupying the extreme point of malignancy, 
202             COLLOID,  GELATINOUS  CANCER.

whilst colloid and the epithelial cancers are in this  respect the mildest
of all.

                  1.  COLLOID, GELATINOUS CANCER.

                   Alveolar Cancer (C. Areolaire).

   In the array of cancers we again encounter a gelatinous, colloid new
growth, namely, gelatinous cancer, better  known  under the epithet
alveolar, derived from its  very frequent alveolar fabric.   This texture
cannot, it is true, alone mark the character of a species.   It occurs,
however, in gelatinous cancer so commonly, and at the same time in so
exquisite  a form, that under alveolar cancer  nothing else is understood
than gelatinous cancer.
   This  species occurs under two forms :
   1. It presents a  yellowish-gray, yellowish-red, here and there color-
less, firm, jelly-like, transparent, tremulous, sizy, and when voluminous,
irregularly clavate, lobulated mass.  This consists of embryonic elements
—for the  most part a cell  analogous in  appearance to the pus-cell—in
an amorphous colloid blastema, and of a  very scanty, very delicate,
fibrous  texture,  mostly  investing  the interlobular clefts.   Bloodvessels
enter into its composition only in very subordinate number.
   2. So-called alveolar  cancer—cited  by  Otho, in 1816, as  a peculiar
kind of stomach-scirrhus—cancer glelatiniforme,  ardolaire of Cruveil-
hier.
   The growth consists mainly and characteristically  of follicles (alveoli)
of either very delicate, pellucid, or of more compact and massive, white,
satin-like, shining fibre-texture, containing a  colorless or a pale yellow,
grayish, diaphanous gelatine.  Sometimes the growth consists entirely
of these follicles, with inconsiderable columns of fibres intervening between
them.   Then, again, in the deeper layers, towards the base of the new
growth, we shall find the follicles separated by a copious, firm, white
fibrous stroma of new parenchyma.  Its quantity stands obviously in an
inverse ratio to the quantity and the grade of development of the follicles.
This is  shown most especially  from the examination of cancers  of  the
stomach and intestines.  The walls are here found considerably thickened,
hard, clavate, the inner layer presenting a  multitude of  collateral and
superimposed  hemp-seed- or pea-sized  follicles, the  innermost  of which
open, collapse, and cast their  gelatine  upon the inner surface  of  the
stomach or intestine.  In proportion to their depth, the follicles are,
with exceptional patches, smaller, whilst the densely fibroid stroma before
referred to gains the ascendency.   This character of alveolar cancer is
frequent both in the stomach and intestines, and may be designated as a
combination of the  alveolar with the fibrous form.
   A closer investigation of alveolar cancer  presents a fibrous texture of
the parietes of the alveoli, and of the inter-alveolar  substance.  Along
with areolar  tissue-like  fibrils, black-contoured granule- and nucleus-
fibres, with similar fibre  elements  arising out  of solidified  blastema  and
uninfluenced by acetic acid, play here a great part.   In the gelatine are
found, besides elementary granules and  nuclei, non-nucleated and nucle- 
COLLOID,  GELATINOUS  CANCER.            203
ated cells, cells with one  or with multiple cells, parent  cells.   Besides
these, there are  present  spindle-shaped,  caudate  cells,—under certain
conditions granule-cells, together with a large proportion of fat-molecule.
Johannes Miiller obtained out of this  gelatine, by boiling, no trace of
gluten.   An alcoholic extract, boiled with water, contained but an incon-
siderable quantity of a substance somewhat akin to ptyalin.
   According to Mulder,  the  main constituent of alveolar  cancer does
not occur at all in the healthy body.   We regard it as the same gluten-
like substance which furnishes colloid (see Colloid), and which, as we see,
constitutes numerous  new growths, both benign and malignant.
   Cruveilhier further  distinguishes a "cancer  are'olaire pultacde," the
follicles of which instead  of transparent gelatine, contain  opaque  pulta-
ceous matter,  in  which Boutin Limousineau  has detected casein.   We
hold this cancer to represent  a transition state of cancerous gelatine to
fat, with its ulterior saponaceous  and emulsive combinations, partly in
the act of granule-cell formation.   The same transformation is witnessed
in like manner in the  first form of gelatinous cancer, and  often affecting
considerable portions of it. It is in its nature analogous with the so-called
reticulum of fibro-cancerous textures.
   Alveolar cancer displays, in a  consummate form, all the characters
assigned, under the head of " Cyst," to the alveolar texture.  In its most
pronounced, that is, its most fully developed state, it offers the following
varieties :
   (a.) The gelatine accumulates in the follicles in so excessive a degree
that the walls of the  alveoli, owing to the  distension, become thinner and
thinner until reduced  to a mere residue.  The  heterologous mass dege-
nerates  into an  almost uniform tremulous jelly, traversed by  delicate
membranous septa,—the  residua of the alveolar walls.  It is, in point
of fact, scarcely to be distinguished from the first form of gelatinous
cancer.
   (b.) The follicles  dilate  with increase of substance  of their walls
(hypertrophy) into cysts, attaining thus to an enormous magnitude. This
excessive development affects the follicles  more and more, in proportion
as they are more peripheral.   The new growth presents an aggregate of
collateral  and superimposed  cysts, one or more of which, at the peri-
phery, are of immense circumference.   This growth resembles the com-
pound cystoid, inasmuch  as a redundant alveolar type is common to both,
a  circumstance readily ascertained in the  instance of alveolar gelatinous
cancer from the more and more dense  fibro-alveolar  structure exhibited
on its cut surface, in proportion as its base is neared.
   The  contents  of the  enormously developed follicles  include  all the
variations observed in cystoids, just as their parietes are  subject to the
same class of diseases.
   The parts most liable to alveolar cancer are the stomach and the large
intestine, the serous membranes and the  peritoneum in particular, the
omentum (less often independently than in association with cancer of the
stomach and colon), the ovary, the bones, in  rare  instances the kidney,
the uterus, and the liver.
   Wherever situate, gelatinous cancer  generally enlarges, and that often
in a short time,  to enormous  masses.   Upon serous membranes,  espe- 
204
FIBRO-CARCINOMA.
cially the peritoneum, it occurs in scattered gelatinous accumulations, in
little  millet- or  pea-sized tubercula, or in  larger masses,—occasionally
as a continuous  bulky growth, which vegetates from  a few points of
adhesion only, if not almost free within the peritoneum.
   Upon the peritoneum the first form is  predominant, but  not to the
exclusion of the  alveolar, the scattered tubercula having the character of
isolated alveoli.   In the ovary the cyst-like alveolar cancer is prevalent,
very often as encysted dropsy of the  areolar cancer-form.   This  form
occurs also now  and then in the bones.
   Gelatinous cancer, and especially the alveolar, is sometimes associated
with other cancers.  This combination, however, with  alveolar cancer,
must be considered apart from the alveolar type.   This type constitutes
every cancer an alveolar, but not a combination with alveolar gelatinous
cancer.  Every  alveolar cancer  may be  regarded as associated  with
fibrous cancer, by virtue of a notable fibrous inter-alveolar substance.  A
combination with medullary cancer is  generally brought about by the
medullary cancer supervening upon the alveolar, the peripherous follicles
of which fill with,  and are eventually overlapped by the looser encepha-
loid mass;  or else, the medullary cancer grows into the cavities of the
alveoli.  More rarely, the gelatinous cancer supervenes upon the medul-
lary, in the cystic and alveolar form.
   Pure gelatinous cancer is the least  malignant of any, and, unless it
prove exhausting by dint of surpassing volume, a dependent  cachexia is
less pronounced than in other  cancers.  It is very rarely the  seat of in-
flammation  and ulceration.   It is for the most part solitary, although
somewhat prone to extend to contiguous organs, and to scatter itself over
serous surfaces,  in the manner already adverted to.

                        2. FIBRO-CARCINOMA.

                         Simple  Carcinoma.

   The schirrhus of older pathologists,  the  only new growth  designated
by them as cancer;  other equally and still more malignant  formations
being by them divided into  sarcoma and fungus.   It is upon  the whole
the most compact in texture, and therefore the hardest of cancer-growths.
Hence, the expression scirrhous hardness,  formerly  employed to denote
in an organized  product a resistance analogous to that of fibro-cartilage.
   In a parenchyma like that of the mammary gland, scirrhus commonly
appears as  a clavate, gibbous,  indistinctly lobulated, somewhat branched,
not sharply defined, very hard, grayish,  or bluish-gray  new  growth,
which has the faculty of dragging  down surrounding textures upon itself,
is of moderate size, of from a walnut to a  duck's egg, is heavy in pro-
portion to its density of texture, and creaks under the knife.
   Several deviations, to be hereafter specified, here present themselves.
We shall, however, limit ourselves in this place to the statement that the
density of the fibrous texture,  sufficiently cognizable with the naked eye,
as also the  hardness, do not  always attain  the presumed high grade.
Under certain conditions, scirrhus becomes tolerably lax and  succulent.
   On a more minute examination, the  principal mass appears to consist 
FIBRO-CARCINOMA.
205
of a fibrous texture, imbedded in which are embryonic  elements, in the
shape of nucleus and cell.   The former gives it  the impress of fibrous
cancer,  and  determines  its  density  and hardness.  The greater the
number  of the embryonic  elements, the more does its fibrous texture
serve as a  stroma for a constituent, whose preponderating mass alters
and determines its characters.
   The fibrous groundwork presents manifold differences with respect to
the form and the arrangement of the fibres.
   1. Very commonly it is  a fibre resembling an areolar tissue-fibre or
fibril, or that of the organic muscles.
   2. Sometimes it is a consolidated, tolerably transparent blastema, in
the act of  splitting into fibres and fibrils, and  presenting a fibrous torn
surface.  In both instances there is an accession of granule- and nucleus-
fibres in various numbers.
   3. In a  case of stomach-cancer it was a dense felt of black, branched,
anastomosing fibrils, similar to the fibrils of fibrin.
   With respect to arrangement:
   1. The fibres for the most part point in  one direction parallel to each
other.
   2. They radiate from different centres.
   3.  Considerable  columns  of fibres  traverse each other at  various
angles, so  that upon a parallel-fibred section we find displayed, here and
there, the  stumps of transversely and obliquely divided  fasciculi.
   4.  The  alveolar fibre arrangement is very frequent.
   The embryonic  elements consist of nucleus  and cell.   The former are
often very numerous, as spherical, shining nuclei, furnished with black
contours.  Not rarely, indeed, the transparent nature  of  crude, cancer
blastema makes it appear as if the cancer consisted exclusively of  these
nuclei.
   The cells present many points of difference.
   They are  round, or  angular, ganglion-globule-like,  or  again wedge-
shaped, caudate, &c.
   There are often present  parent-cells,  which become developed into
alveoli;  and upon a cut surface we meet with these, visible to the naked
eye, in the shape of prominent, transparent vesicles, imparting to  fibro-
carcinoma  the aspect of a  glandular structure.  Bloodvessels are not
wanting in scirrhus, alth'ough their abundance is  not very great.  Lob-
stein is wrong in asserting these growths to be non-vascular.
   Although the mass  of  fibro-carcinoma is not altogether  dissolved by
boiling, it yields, nevertheless, a notable amount of gluten.   Compared
with medullary cancer, it contains a  smaller proportion of fat (accord-
ing to  Martigny, a soft fat; according to Breschet, cholesterine).
   Acetic acid  certainly does (although denied by Miiller) render the
cells more limpid, throwing nuclei and nucleus corpuscles with black
contours and some little shrivelling, more into relief.
   No  other cancer possesses, in so high a degree as the fibrous, the ten-
dency to condense and corrugate  the  textures, in which it has taken up
its seat, or to  drag  down upon itself contiguous, especially  if they be
membranous, parts.   The invariable  consequence  is the wasting of the
cancerous  organs,  and the shortening, with consolidation,  of implicated 
206
FIBRO-CARCINOMA.
membranous formations.   Fibro-carcinoma is slow of growth, and slower
in proportion as the fibrous character predominates in its fabric.   It will
thus vegetate long, without producing any visible cachexia, provided it
do not interfere with the function of any vital  organ,  and provided it
remain solitary.  A  more rapid'growth is always conditional upon an
overpowering development of embryonic elements out of fluid blastema ;
which latter, in the inverse ratio of its plasticity, relaxes  the texture of
the scirrhus, drenches it, and causes it to swell.   It is often of a medul-
lary (encephaloid) character, giving rise  to a combination of fibrous  with
medullary cancer, in the shape  of a more or  less intimate blending of
the two.   With this, there is always a  simultaneous  increase of vascu-
larity in the cancer-parenchyma, hyperaemious tumefaction, and inflam-
mation ; frequently, also, the development of a reticulum.
  The presence of this  reticulum changes fibrous cancer  to that form
which Johannes Miiller has  designated carcinoma reticulare or reticula-
tum.   That is to say, we conceive ourselves to be warranted by experi-
ment in assuming the latter to  be fibrous cancer, plus the reticulum,—
fibrous cancer in the aforesaid progress  of rapid and redundant growth,
and incontinently passing into  congestion and inflammation.   Its form-
elements are identical with those of pure, fibrous cancer; although the
embryonic elements and bloodvessels predominate.   The capacious  cells
and membrane-clad cavities met with occasionally in carcinoma  reticu-
latum by Johannes Miiller, are probably nothing more than the follicles
of an alveolar texture that has invaded the fibro-carcinoma; such follicles
being replete with the substance of the reticulum as a product of inflam-
mation.  This  so modified fibro-carcinoma frequently  occurs  in   the
mammary gland,  attaining, for the reasons stated, a greater volume  than
pure, fibrous cancer.
  Fibrous  cancer occurs (primitively and in a developed  form), in the
mammary gland; in the stomach, perhaps, still more frequently ;  in the
colon; in the submucous areolar  tissue;—more rarely in the  vaginal
portion of the uterus, upon serous  membranes, and in  the subserous
areolar tissue.  Again,  as an expansive degeneration of  the  omentum
and of the mesentery; in the salivary glands;  in the fibrous tunic of the
bronchia.   In several of these, as well  as in other  structures,—for ex-
ample,  the ovaries,  the brain,—there occur  cancerous  growths  of
embryonic composition, and in all likelihood of fibro-cancerous nature.
   With respect to shape, fibrous cancer  in and upon membranous struc-
tures deviates from the clavate  form before described.   In the stomach,
for instance, it represents degenerations, spreading along  the course of
the submucous, areolar stratum, and only here  and there swelling into
knobbed projections; whilst in the intestine it assumes the  annular
shape.  Upon  serous membranes, the pleura  for example, it sometimes
occurs as a fibroid exudate, that is, as a densely fibrous,  whitish,  sha-
greened  mass  of  unequal thickness, branching, as if  outpoured,  or
dropped here and there, over the surface.
   In the bones it appears in the shape  of roundish  knobs, imbedded in
the  diploe of  the cylindrical  bones, over which the compact covering
plate becomes wasted by compression, giving occasion to spontaneous
bone fractures. 
MEDULLARY CARCINOMA.                 207
  In the frequent cases of cancer of the stomach we have  the best op-
portunities for studying the character of the cancerous degeneration of
muscular tissues.  It consists in a development of white interfascicular
striae, imparting  to the fleshy tunic a white-celled  aspect.   The white
striae consists of  accumulations of nuclei, cells, and  lastly, fibres, which
receive and so to speak encapsule the swollen, reddish, or yellowish red,
exsanguine muscle-substance.   The formation of these septa multiplies,
and they increase in volume until the muscle has entirely given way and
perished.
  Fibro-carcinoma  is, for the most  part,  the  primitive cancer  in  the
organism, and very rarely indeed the secondary.   The  cancer-growths
consecutive  to it have, in proportion as they multiply, more and more
the character of the medullary  form.  Even the occasionally more rapid
development  of fibro-carcinoma takes place under the supervention of
medullary  carcinoma, and  the affection of the  implicated lymphatic
glands occurring in the consecutive series is of the same medullary cha-
racter.   In like  manner  the  extirpation of fibrous  cancer  is generally
followed by medullary growth.
   In conclusion,  we would  advert to certain  malignant accumulations,
proved by antecedent circumstances to be undoubtedly cancerous. These
infest bone, the ovaries, again the mediastina, the retro-peritoneal space,
lastly, the intermuscular  areolar tissue; and they are distinguished for
the  great  bulk to  which  they attain.   As regards  their  elementary
fabric, they are almost always embryonic structures, that is  to say, they
consist of nuclei and spindle-shaped or caudate cells,  which last, by their
arrangement, impart  to  the whole the  semblance of fibrillation.  The
intercellular  substance (blastema) is very scant;  and the heterologous
mass is consequently very dense and  firm.   They  are to be  regarded on
the one hand as embryonic fibre-cancers;  on the other, as kindred with
the firmer varieties of medullary cancer.

                      3. MEDULLARY CARCINOMA.

   In every way  the most malignant  heterologous growth, described by
Burns as spongioid inflammation ; by Hey, and afterwards by Wardrop,
as fungus haematodes ; by Abernethy as medullary sarcoma ; by Monro
as fish-testicle-like (soft roe-like) tumor ; by Laennec as  encephaloide ;
by Maunoir as fongue medullaire.   All  these appellations serve well to
designate the external characters of this  new growth; that of fungus
haematodes being, however, applicable to a  combination of this malignant
growth with redundant vascularity.   (See New Growth of Bloodvessels.)
   If, for the  sake of unity and  clearness, we  select for our  principal
delineation, medullary carcinoma in its  most marked form,  and with all
the attributes of the most malignant cancer, we must  preface the descrip-
tion by admitting that in the instance of  no other cancer are more varia-
tions from this cardinal character cognizable.
   In this, its exquisite form, medullary  carcinoma certainly does offer a
striking  resemblance with the brain-medulla of younger individuals, or
with the  testicle of fishes; namely, a soft, semi-fluid, when present in
large quantity, fluctuating, white, or under certain  conditions, reddish- 
208
MEDULLARY CARCINOMA.
white or gray, yellowish-white, red or russet, or even in various  degrees
blackened, heterologous mass.
  As an  independent  tumor, its cut surface exhibits either a perfectly
homogeneous or else a  variously  cancellated, lobulated, more or less dis-
tinctly fibrous structure.   When pressed or scraped, the cut-surface also
yields a perfectly homogeneous  substance out  of a parenchyma which
mingles with  water to a uniform  mass.  Or, again, the  entire  mass
separates  into a looser medullary  constituent, and into  another more
consistent, which furnishes a  sort of stroma for the former, and  appears
as a more or less fibrous or villo-membranous framework.   The  relative
quantity of both varies considerably.
  These relations  are  subject to great variations, determined for the
most part, by the  degree of  consistency of  the heterologous  growth  as
cognizable with the naked eye.   There  are  some growths of this  kind
which recede  so far from the medullary character, as hardly at all  to
tally with  the description above given of medullary carcinoma.  Still,
the occasional blending or interlacing of such deviating structures with
exquisite  medullary carcinoma,  in  one  and the   same  organ, the em-
bryonic condition of their elements, their rapid growth, and their volu-
minous character, seem to justify their mention in this place.
  Thus there are,  on  the one  side,  medullary carcinomata  of  almost
cream-like fluidity,  or which,  infiltrated into the textures, into the
medullary system of the bones,  or into  the  sheaths of organs after the
destruction of their parenchyma,—for example,  the neurilemma of the
pituitary gland, the capsule of the spleen, &c,—resemble a milky juice.
No stroma enters into their  composition.  On the other side, there are
congenerous growths—heterologous  masses,  very  commonly regarded  as
medullary carcinoma in a crude state, that  is, in a primitive stage  of
the true medullary encephaloid—which, in point  of consistency, do not
yield to the fibroids, to fibro-cartilage.  Amongst these  denser masses
there is one particularly remarkable—namely, an  often very  volumi-
nous, in appearance, and  also in reality, unevenly-lobulated,  homoge-
neous,  whitish, or  yellowish-white,  heterologous  mass, which offers  a
striking analogy with  the virgin mammary gland, especially in point  of
firmness and of elasticity.  It is  probably to this that Abernethy applied
the term mammary sarcoma.  Others present the aspect of a glandular
structure ; for example, of the texture of the salivary glands, or of the
cortical substance of the kidney.
  Lastly, the vast  difference in  bloodvessel-formation, referable to the
structure of medullary carcinoma, is perceptible even to the naked eye.
In no other parenchyma does it appear so frequently in redundance  as
in medullary carcinoma.  Conformably herewith  none is  so susceptible
of hyperaemia, of tumefaction, and of rapid growth ; in none do hemor-
rhage (apoplexy) and  inflammation so  readily occur—processes,  upon
which the anomalous coloration  of genuine  white medullary carcinoma
obviously  depends.
  The differences,  however,  discoverable with  the naked eye in carci-
noma, are slight compared with those revealed in the elementary texture
of medullary carcinoma, with the aid of a magnifying power.
  They are divisible into those  recognized by the naked eye as compo- 
MEDULLARY CARCINOMA.
209
 nents of medullary  matter,  and into those which, at the  same time,
 present an intercellular substance,—a stroma.
   With reference to the former, there are medullary carcinomata.
   (a.) Consisting of granulated cells with a more or less distinct nucleus,
 and resembling pus-globules.
   (b.) Consisting of smaller and greater, granulated, round,  or angular,
 protuberant cells, more or less resembling the cells of tessellated  epithe-
 lium, the hepatic cells, the ganglion globules, and provided with one or
 several nuclei.
   (c.) Consisting  of  spindle-shaped and  caudate, nucleated  cells, fibre-
 cells, amongst which are many others, both spherical and oval.
   (d.) Consisting of elliptical corpuscles, of Tou to g'o of a millimetre in
 circumference, and furnished with one or two nucleoli.  They have the
 significance of a (heteroplastic) transcendent development of  cell  nuclei.
   (e.) Consisting of spherical or oval  corpuscles corresponding in size
 and tendency with the cell-nucleus.
   (/.) Consisting of elementary  granules down to the finest molecule-
 mass, with scanty nucleus formations in progress of development.
   (g.) A further element concurrent with those  specified at  b,  are  pouch-
 like formations (see Metamorphosis of Blastema), and chiefly the parent-
 cell, which often constitutes a prominent  element in medullary cancers.
 It forms  here again  the  groundwork for the alveolar textural type of
 medullary cancer.
   These  elements occur  predominantly, it may  be, in the  one or the
 other form, but intermingled  with others.  Viewed with the  naked eye,
 the .elementary composition of a texture is, even to the well  initiated, a
 matter rather of conjecture than of any certainty.  The consistency and
 density of a texture may vary infinitely, being dependent upon the cha-
 racter of  the intercellular  substance.  It is only where there is the ap-
 pearance  of fibrillation that  we  may  perhaps infer a composition  of
 spindle-shaped or caudate cells.
   Differences more important affect the  character of the intercellular
 substance, and of  a stroma in which the elements adverted to lie imbed-
 ded.   This stroma is developed either out of those elements themselves,
 which, according  to  the   laws  of the  cell theory, form into a fibrous
 skeleton work;  or  else it springs immediately out of a  consolidated,
 amorphous, intercellular substance.   Both together  occasion, in medul-
 lary carcinoma, a  special structure manifest  to  the naked  eye, in the
 shape of a variously  disposed  fibrillation  and lobulation,  &c, the cha-
 racter of  which so greatly modifies the consistency of  the  heterologous
 growth.
   In this  regard, we have the following forms,  some more or  less  cogni-
 zable with the naked eye.
   (a.) A  medullary carcinoma, with an amorphous fluid, or  semi-fluid,
 intercellular substance.  The  aforesaid elements vegetate in a thin or a
 thickish medullary juice.   It  is  represented in the  very lax, milky  or
 cream-like encephaloid cancer.
   (b.) A  medullary  carcinoma,  with a  solidified, amorphous,  or else
 striated,  indefinitely  fibrous,  intercellular substance, interspersed with
roundish and fibro-elongated nuclei.
  VOL. i.                           14 
210
MEDULLARY CARCINOMA.
  (c.) Medullary  carcinoma,  with  a stroma consisting  of fibre-cells
(spindle-shaped, caudate) arising out of the development of the elements
of the medullary substance itself,  with consumption of the intercellular
substance, and condensation of the heterologous growth.
  (d.) Medullary  cancer  with a delicate hyaline,  structureless, or else
an  opaque, striated,  membranous  stroma, studded  with  elementary
granules and nucleus formations, or fibrillated like areolar  tissue; which
stroma,  at the same time, forms the groundwork for the vascularization
of the alien growth.   Its interspaces are filled with a loose, fluid medul-
lary matter, and it is  easily thrown into relief if the tumor  be scraped,
pressed, or simply steeped in water.   In villous  cancer this stroma ap-
pears developed into a main constituent.
  (e.) Medullary carcinoma with a more or less developed fibrous stroma,
whose fibre-elements,  upspringing from a solidified blastema, now re-
semble fibro-cellular tissue, now  organic  muscle-fibre.    It represents
either a scaffold-work  or a stellate structure,  the  gaps being filled up
wit^h embryonic elements.   Even with the naked eye it is  discernible as
denser striae, disposed  as aforesaid, and  remarkable for their whiteness
and their tendon-like lustre.  This  stroma has  frequently  the signifi-
cance of fibrous cancer blended with medullary.   It is, however,  often
enough an innocent fibroid growth, which may very possibly become the
seat of so-called ossification (bony concretion).   Hence the  extraordinary
phenomenon  of medullary cancer becoming   traversed by  a concrete
skeleton-work, in the midst even of soft parts.
  This seems the proper place to take into consideration another combi-
nation with a benign new growth in the shape of a  stroma, namely, that
with normal bone-texture.
  A normal bone-texture  occurs  very  frequently in  medullary cancer
affecting bones, as a  thorny or stellate skeleton  or  stroma.   This is,
however, generally limited to the base of the alien growth.   Greater in-
terest attaches to  a  medullary carcinoma,  possessing throughout a firm
bony stroma,  which,  as a finely  cancellated  diploe,  receives  into its
cancelli the soft parenchyma of  the medullary cancer, to which it bears
a relation similar to that of bone  to its  normal medulla.  This  growth
certainly affects bones and their vicinity, although  not exclusively.  It
is what Johannes Miiller termed malignant osteoid.   The bony texture
entering so largely  into  its composition,  is a very remarkable  pheno-
menon, but its nature is simply that of a  benign stroma for the reception
of a cancerous, soft parenchyma.
  An important part is assigned, in medullary carcinoma, to the parent-
cell, and to the alveolar textural type resulting from it.  We have often
examined medullary carcinomata which mainly consisted of parent-cells.
One consisted entirely of parent-cells, and being  in the progress of fatty
conversion, it presented a very peculiar aspect.   Numerous liver cancers
were found to consist  of a fish-roe-like accumulation of yellow, poppy-
grain-sized granules—parent-cells, replete with fat-containing filial cells
—loosely connected together by a liquid, lardo-glutinous, yellowish-brown,
intercellular substance.
  Both  forms of the alveolar texture occur in medullary cancer, the true
alveolus, and also  the aciniform, excavated body.  Both, more especially, 
MEDULLARY CARCINOMA.
211
however, the latter, determine the likeness of many  medullary cancers
with gland-textures.  Both may coexist independently of each other, or
the  second vegetate as  an endogenous growth within  the alveolus.
Medullary carcinoma occurs no less frequently as cysto-carcinoma.
   Upon  the dura mater,  heterologous formations are not unfrequent,
which, closely resembling granular cortical substance  of the kidney, con-
sist of spherical or roundish rolls of caudate cells, imbedded in a layer
composed of the same elements.   They are gorged with a  white  medul-
lary juice, are for the most part considerably vascular, and of a  turgid,
soft consistence.
   Medullary cancer consists  mainly of albumen, with fat, according to
Wiggers a phosphorus-holding fat (brain-fat), according to Gugert cho-
lesterine, and, as Eichholtz contends, with pyin.
   Medullary carcinoma ordinarily assumes the form of roundish tumors;
not rarely, however, both primarily  and consecutively, that of infiltra-
tion into the parenchyma of every variety of organ.   To the naked eye,
the tumors often seem sharply sundered from the surrounding textures.
Nevertheless, the impossibility of dissecting them out, without injury to
those  textures, and a narrower  scrutiny, teach us that they penetrate
into neighboring textures,  and moreover,  that  they grow in suchwise as
to infiltrate and destroy the textures in their immediate  circumference.
In other cases, however, they are capable of being shelled out of an organ,
having a very  delicate,  areolar  tissue-like,  vascular  sheath.   Such
growths are generally furnished with a membranous stroma, are more or
less distinctly lobulated, grow independently, and simply jostle the tex-
tures out of their place.
   Medullary cancer in the one  case grows  to an enormous  volume, in
the other case is remarkable for its numerical dissemination.  Its increase
in volume, especially when rapid, takes place  through the accession of
embryonic elements.   Hence the circumstance that old medullary carci-
nomata which suddenly undergo great augmentation of volume, have, at
their base only, a solid and textural stroma, or it may be a bony skeleton.
Medullary carcinoma is, both in its  development and in  its subsequent
course, the most acute of all  cancers.  As a solitary  growth in the
organism, it arrives very  rapidly  at its  full volume, and throws out a
multitude of secondary tumors with the same celerity, not unfrequently
under the accompaniment  of very acute typhoid fever. The more hurried
its development, the more does the embryonic form (elementary granule,
nucleus, fluid intercellular substance) of its elementary composition, that
of genuine encephaloid,  predominate.  Wherever cancer-production is
acute, its form is the medullary.
   Conformably with this, every other cancer, goaded  into redundant
growth,  degenerates into the  medullary,  that  is,  enters irito combi-
nation with the latter, the  new accession being the medullary.  The
fungus upspringing from the ulcerating base of a cancer, is in its nature
medullary.  Every consecutive, every general, cancer-production is in-
variably medullary, nor is there any organ in which medullary carcinoma
does not occur, either primitively or consecutively, as part and parcel of
general cancer production.
   In point of fact, medullary carcinoma occurs in organs in which  no 
212
MEDULLARY CARCINOMA.
other cancer, least of all fibrous cancer, ever occurs ;  as in the liver, the
kidneys, the lungs, the testicles, the lymphatic glands.
   In the bones,  medullary cancer is frequently  distinguished  by  a
lamina-stellate, thorny bone-skeleton, the form often  obviously depend-
ing upon the nature and  arrangement  of the stroma.  Sometimes  it
causes the bone  to rise up  into  a bone-capsule;  more  frequently, how-      I
ever, it dissipates it into  a voluminous honeycomb mass.
   In medullary carcinoma the cancer-crasis has attained its highest
grade.   It  experiences  a  further  augmentation through  infection,—
through reception of this, the most readily  absorbed cancer blastema,
into the  lymphatics  and bloodvessels.   The  products  of inflammation
placed  under its  influence  are eminently albuminous, white, opaque
exudates, and these become developed into medullary cancer, upon serous
membranes, or as cancerous lung hepatization, and  the  like.   The same
thing happens with respect to coagula within the vascular system, both
in the greater vessels and in the capillary system; by dint of an aliena-
tion of the fibrin, they bear evident marks of the cancerous character—
cancerous phlebitis, capillary phlebitis (deposit).
   We cannot subscribe to the assumption of regular stages of medullary
cancer,  of a stage of crudity, of softening,  of ulceration, &c.J these being
conditions not correlated by any necessary causal links.
   That which is regarded  as  crude medullary  cancer, is the variety
furnished with a  consolidated  intercellular  substance.  Softening  ob-
viously  characterizes the form  of medullary cancer luxuriating as the
true encephaloid, and it attaches equally to that  which originates  at
once as such.  Lastly, the ichorous and ulcerous destruction of the struc-
ture is a consequence of its inflammation, that is,  of accidental disease of
the tumor.
   Medullary carcinoma frequently destroys life as a  consequence  of its
surpassing growth, either as  a  solitary alien  formation, or as one dis-
tributed  over several organs,—through cachexia and exhaustion, through
hindrance to the  function  of  important organs ; for  example,  of  the
digestion, of the larger  veins,—the vena cava,  by  its closure;  again
through hemorrhage; finally, through inflammation and  ulceration, often
under the symptoms of cancerous infection of the blood.
   The  substance constituting  the  reticulum occurs, especially in  the
softer forms of medullary carcinoma, in large accumulated masses.  In
the forms furnished with a fibrous or membranous stroma it follows for
the most part the distribution of the latter, and  therefore of its blood-
vessels.
   Contradictory as it may seem, after what has been stated, in no cancer
is a spontaneous or natural process of cure brought about so frequently
as in the medullary.
   Such a process is the sudden and rapid destruction of the  cancer by
ulceration and necrosis, as  observed not unfrequently in the dead subject,
in medullary cancer  of the womb.   Such a process,  again, is  the  meta-
morphosis described, under the general heading of "Cancer,"  as saponi-
fication and incrustation.  Moreover, it is known as a fact, that medul-
lary  carcinoma  in the  subcutaneous  fat-layer will disappear  through
resorption, and return again. 
CANCER  MELANODES.
213
  With reference to the fungus haematodes of Wardrop, and the medullary
carcinoma  of Abernethy, we  feel compelled  to  subscribe to Walter's
verdict, namely, that they are identical.  For we have always found the
former to resolve itself, when closely examined, into medullary carcinoma
with luxuriating vascularity.   Assuming,  therefore,  the term "fungus
haematodes" to designate a mere accidental condition of medullary carci-
noma, there  might be no impropriety in  abandoning it, or in under-
standing by it only a highly vascularized medullary carcinoma.
   On the other hand, it is requisite to bear in mind that which we have
stated under the head of bloodvessel  formation, namely,  that assuredly
there are alien  growths, which,  although  primitively mere bloodvessel
luxuriations, may subsequently combine with  cancer, and this  possibly
without  any concurrent anomaly of the general crasis, through  mere
impairment of the blood held within their own capillary system.   We
must here once more refer to the results  of Van der Kolk's injections of
the  growths in question, which induced  him to discriminate  between
fungus haematodes and medullary carcinoma.
   That medullary carcinoma has some sort of affinity to the medulla of
the  nervous system, appears, not alone from its  general  aspect and
chemical composition, but also from the fact that, in medullary cancer
 of the eyeball, the tumor springs from either  the  retina or the optic
nerve, and  that nerves speedily  perish within the range of medullary
 tumors.
   To  medullary carcinoma we shall annex, as varieties, certain growths
 which bear an affinity to it.

                       (a.)  CANCER  MELANODES.

   The entrance of pigment into the composition of any cancer converts
 it into cancer melanodes.  Nowhere, however, does this substance  occur
 in so marked a degree as in  a cancer closely  resembling the medullary.
 It may indeed be  said, that cancer melanodes  (so-called malignant  mela-
 nosis) is but a medullary carcinoma modified by pigment, an idea pro-
 mulgated by Meckel, von Walther, and others, in their day.
   Cancer  melanodes,  as  an independent  tumor, presents most of  the
 physical aspects of medullary carcinoma.   Its  cut  surface  appears to
 the naked  eye either  homogeneous, or  fibrous, or lobulated, and of a,
 more  or less firm  and brain-like consistence.   A closer inspection of it
 reveals elementary granules, nuclei, cells of spherical or oval, caudate,
 elongated, angular shape, and along with  these  the most varied  inter-
 cellular substances and stromata.  Melanotic  cancer imitates most com-
 monly the encephaloid variety of medullary carcinoma, with  round and
 caudate cells, and a membranous—a villo-membranous—stroma.
   These alien growths are chiefly marked by their black or brown-black,
 brown, bronze-green,  or rust-brown  coloration.  The  first glance at
 these often numerous tumors generally suffices to show that the color is
 merely accessory.  For, amongst thoroughly tinged, we meet also with
 perfectly colorless, white, heterologous growths ; and again between the
 two extremes others pigmented in the most various forms, in dotted or 
214
CANCER  MELANODES.
stellate patches, or in ramifying anastomosing striae.  The white growths
are recognized at once as genuine, ordinary, encephaloid cancer.
  A minute examination detects, according to circumstances, a  greater
or lesser  proportion  of  pigment, and, even in the blackest, elements
enough—cells and intercellular substance—free from pigment.
  Pigment occurs free or inclosed in cells, in all the forms enumerated
under that heading.   Its basis  is, as there taught, and especially as the
examination of acutely produced or redundantly growing cancer  mela-
nodes  incontestably proves, haematin  in a free  and dissolved state, or
else blood-globules,  with their  pigment,  in  substance.   In the  latter
case, the alien  growth resembles  a hemorrhagic effusion, in which  are
found  along  with the blastema  the  elements of medullary  cancer in
various phases of coloration and of conversion into pigment.
  Chemical analysis  must needs  detect the constituents of medullary
carcinoma, and the pigment with its  base.  Barruel  and Henry have
discovered, in the melanosis in man, haematin, fibrin, three kinds of  fat,
a considerable amount of phosphate of lime, and iron.
  Like medullary carcinoma, cancer melanodes is found to infiltrate the
textures of parenchymata,  as also of membranous parts, the dura mater
for instance.
  By reason  of its pigment, melanotic cancer may be studied at its out-
set in very small point-like portions, which, under  a magnifying power,
appear minutely ramified.
  Like genuine medullary cancer, the melanotic often attains to an ex-
traordinary circumference.   Its simultaneous occurrence in many, if not
in most organs, is, however, still more usual.   Its multiplication is often
very rapidly  brought about, with  the  concurrence, it may be, of acute
typhoid fever.  No organ is exempt from the disease.  Even when at-
tacking all, or several, organs simultaneously, it may grow inordinately
in a single one or more than one, in which case the liver is  almost always
found  to be the organ of predilection.  We  have seen it in the brain
and about the nerves, at  the eyeball, in the lungs, in the thyroid gland,
in the liver,  spleen, kidneys, bones,  lymphatic  glands, ovaries, in and
beneath the intestinal mucous membrane, between the mesenteric layers,
in the skin and subcutaneous areolar tissue, upon serous membranes, in
the dura mater, upon  and within the heart.
  In  the majority of cases, cancer melanodes is found to affect middle-
aged or still older individuals.   Both we ourselves and others have how-
ever observed it with little  less  of frequency even in youth.
  The crasis upon which  cancer  melanodes is  based, is  without  doubt
essentially the  medullary.   The  pigment has, however, still  to be ac-
counted for.  A special dyscrasial character of the haematin and of the
blood-globules might  here  suggest itself, a crasis analogous  to the con-
stitution of the portal blood with a continuous excess of aged and spent
blood-globules which have reached their climax of coloration in a defibri-
nated  plasma,  the ready suscipient  of haematin.   Such  a  view would
find support  in the cachexia so  often concurrent with  melanosis,  and
so characteristic  of a predominant venous  constitution,  with a  vivid,
brownish coloration of the common integuments.  And to this might be
added  the fact, that cancer melanodes is more  than ordinarily rich in 
TYPHOUS SUBSTANCE.
215
pigment  when  occurring in the liver and the choroid plexus, in which,
for various ends, pigment is thrown out from the spent blood-globules
even in the physiological state.
  But, apart  from numerous exceptions in  this last respect, we must
guard  against  overlooking  very important local processes  in cancer
melanodes, where the base of the  pigment is furnished, not by the
general circulation, not by haematin, but by substantive blood-globules.
Here the  question is, first, whence is derived the blood as the  basis  of
pigment ? and, secondly, what causes the transmutation of the blood  to
pigment ?  The latter question is the more pertinent that  in medullary
carcinoma hemorrhage is common enough without any entailment of the
pigment of cancer melanodes.  In  reply to the first query,  we have  to
express a well-substantiated conviction that the blood furnishing the base
of the  pigment in cancer melanodes is  not—at  least not mainly—an ex-
travasate out of  a perfected system of  bloodvessels; but  blood newly
formed in parent-cells, and transformed into pigment either within these
cells or upon their breaking up.
   This metamorphosis within parent-cells engaged in a  process of radia-
tion and ramification into a  capillary system, explains the  circumstance
that the  pigment,  in  its first manifestation in  the parenchyma  of a
genuine  white medullary carcinoma,  appears in the  form  of finely
branched and stellate points and patches.
   Cancer melanodes generally proves fatal in its excessive,  multiple pro-
duction,   through the  exhaustion  and  wasting corresponding  to  such
redundant alien  growth.   In rare  instances cancer melanodes enters
upon a process of ulceration, and kills  through  hemorrhage or simple
exhaustion.

                        TYPHOUS SUBSTANCE.

   The product of typhous blood-stasis deposited, in intestinal typhus in
the follicular apparatus of the bowel, in broncho-typhus in  the bronchial
glands, and probably in plague-typhus in different superficial lymphatic
glands, appears to us so analogous in many points with medullary carci-
noma that we  do  not hesitate,  in accordance with an opinion  long enter-
tained, to award  it a place here.
   Typhous substance  appears, in  extreme cases where it  is rapidly
produced  under violent symptoms, as a grayish or whitish red, or a gray,
or a white, lax,—in the mesenteric glands almost diffluent,—fluctuating,
medullary substance, which,  in  its external features, bears the most
striking similarity to encephaloid cancer.
   This typhous substance, after abiding for a  certain period in its pri-
mitive crude state, enters into a process  of loosening up and sloughing,
which becomes the medium of its removal from  the normal textures.  In
some instances, and some epidemics, this breaking up manifests itself  as
a development  of the typhous  substance, both in the  follicular apparatus
and  in the lymphatic  glands, to  a luxuriating,  bleeding,  partially
necrosed, fungoid growth (Hensinger's muco-membranous fungus).   The
latter in  particular, offers the greatest analogy with medullary fungus.
  The elementary composition of the typhous substance is  embryonic— 
216
VILLOUS  CANCER.
elementary  granules, nucleus-forms.   Nucleated  cells are  commonly
present in inconsiderable number.  This  relates,  however,  more espe-
cially to typhous substance in the bowel.   That in the mesenteric glands
frequently shows nucleated cells,—even parent-cells with several nuclei.
  Even the  albuminous constitution of the typhous substance, and the
genuine typhous crasis itself, to which fibrinous exudation  is a stranger,
involve an analogy with medullary carcinoma and its crasis.   All fibri-
nous products occurring in the  typhous substance itself, or along with it
upon the  same textures—the  intestinal  mucous membrane—or in  any
other organ, are not proper to  the true typhous process, but to a secon-
dary croupous crasis, into which the typhous crasis so often degenerates
at various periods of its progress.

                         VILLOUS CANCER.

  An  alien growth, whose  cancerous nature  is incontestably proved,
both by its  attendant cachexia, and by its frequent alliance with the
cancers before discussed.   Owing to the  close affinity of its elementary
structure  with that of medullary carcinoma, we place it next in array
with,  or as a variety of, the latter; with which, moreover, it has in com-
mon the loose consistency, the  abundant vascularity, and the proclivity,
to hemorrhage and to inflammation.
  So far as we know, it occurs solely upon membranes,  for the most
part,  the pituitous, and  most particularly upon  that  of the urinary
bladder, as so-called villous muco-membranous tumor.  It also, although
far  less frequently, affects the  common integuments and  serous mem-
branes.
  At the  outset, it appears as a delicate, cord-like  excrescence of vari-
ous length, which arises out of the aforesaid textures  with a  seeming
longitudinal fibrillation, diverging at its free extremity into  branches and
twigs.  Hereupon, if not before, it forms  into  delicately membraned
villi, and with this expansion of its texture, bulges at its free  end into a
club-like or cauliflower shape.   This section of  the excrescence invaria-
bly contains a whitish, or  reddish white, encephaloid sap.   At this point
it is particularly vascular, and, in its recent state, of a purple tint.
  A minute inspection shows the alien growth to consist of a fibro-mem-
branous  texture, densely  involuted at  the pedicle, and  developed at the
free extremity into a stroma for the reception of the imbedded encepha-
loid.   This  stroma is a  delicate,  structureless or striated,  fine-fibred
membrane,  studded with elementary granules  and nuclei,  whilst the
encephaloid  sap consists  of elementary granules, nuclei, and cells  of
every variety of form.   Such excrescences not unfrequently vegetate in
great numbers, either  scattered  or densely grouped, upon the  mucous
membrane of the bladder, imparting to it a long-drawn, villous aspect,—
a condition  ascribed by Andral  to a preternatural development of the
muco-membranous villi.
  It is very common  for them  to vegetate particularly  densely  on a
circumscribed patch, to  become blended, at the  pedicle and at the  ex-
panded points, into a diffuse, roundish head, furnished with a neck, which,
if it contains much of the encephaloid juice, presents a uniform, pulpous 
EPITHELIAL CANCER.
217
consistency, and a superficial lobulation, whilst, in the opposite case, its
periphery is villous.
   The growth often bleeds spontaneously, and its excessive vulnerability
occasions, upon  very slight injury, exhausting hemorrhage.
   From the above  description, the medullary, cancerous nature of the
alien growth is  manifest, particularly its analogy with that encephaloid,
medullary  carcinoma, provided with  a stroma.  It is  clearly nothing
more than  medullary carcinoma with predominant stroma-formation.

             EPITHELIAL GROWTHS, EPITHELIAL  CANCER.

   These growths are without doubt often  merely local,  and curable by
extirpation.  In many  cases, however, notwithstanding precisely the
same morphological and chemical relations, they accord so entirely in all
their manifestations with the cancers, that we  classify them  with  these
as a further variety of medullary carcinoma, to which in their lineaments,
also, they approximate  the most nearly.
   Their occurrence  wTe believe to be limited to the mucous membranes
and the common integuments.  We have  seen  them  upon the mucous
membrane of  the larynx and trachea; of the stomach,  the rectum, the
urinary bladder ; upon  and in the common  integument, and in  the subcu-
taneous textures of the lips and face; in the scrotum, glans, and prepuce ;
in the external  labia pudendi;  upon the skin of  the lower extremities.
In a parenchyma we have met them  but once,  namely, in the  liver,
where they were encysted in a capsule of fibro-cellular tissue.
   Upon mucous membranes these alien growths  usually appear as rather
thickly  pedunculated,  roundish,  cauliflower-like,  or warty,  leaf-like,
stella-clavate,  whitish,  reddish-white,  purple,  vascularized,  sometimes
tolerably firm, often flabby, very vulnerable tumors, easily rent asunder
by compression.  Upon the  common integument  they sometimes  form
similar, now and then tolerably voluminous, tumors.  More frequently,
however, the alien growth  appears  as a diffuse degeneration of the skin,
which  presents  a  warty, foliated  surface, overgrown with luxuriating
papillae, or else, under different structural relations of the new growth, a
gland-like,  sore, whitish-red,  or red patch,  which, under sloughing and
offthrowing of the alien growth, degenerates into  one or several ridge-
bound  ulcers.
   A more minute  examination shows these out-growths to consist alto-
gether of cells,  which have hitherto seemed to us perfectly analogous,
both in themselves and in their development, with the epidermidal or the
greater epithelial cells of the tessellated structure.   The mature cells are
often of colossal size, flattened, mostly rhomboidal, furnished with one or
two  oval,  reddish,  or   yellowish-red  nuclei.   The younger  cells are
smaller, roundish, spherical,  limpid, or, around the nucleus, granulated
in the figure of a sharply defined areola; whilst  roundish, pale-red nuclei
are present at their side.   The  older cells  are  of scale-like flatness,—
their nuclei indistinct, or, it may be, completely obliterated.
  In ulterior development the cell does not surpass—
  (a.)  A lengthening in one direction, with transformation to a rhomb
or to a riband-like layer terminating at both ends in a short apex. 
218
EPITHELIAL CANCER.
  (b.) A parent-cell, within which occurs a second generation of cells, a
development indicative of an alveolar disposition in the other surrounding
elements.
  These elements are held together by a very scanty, imperceptible, in-
tercellular substance, and  give way under moderate pressure, or without
this, under the influence of acetic acid, or of other acids which serve to
dissolve the intercellular substance.
  The cells themselves manifest towards acetic acid relations varying with
their age, the older ones not being changed, the younger ones becoming
more transparent and  gradually  dissolved by it, whilst  the nuclei  are
brought more  distinctly into relief.   When rubbed  up with water they
impart to it a whitish turbidness, and the young cells lend to their laxer
bond-substance an encephaloid aspect.
  The secondary arrangement of these elements is very remarkable.  It
consists:
  (a.)  In their arraying themselves in  warty,  or   warty layer-like
growths.
  (b.)  In their arraying themselves in  cylindrical  or  facetted fibres or
cylinders, which, gathered together into  fasciculi, give the new growth a
fibred structure, a fibrous torn surface.
  (c.)  In alveolar order.   Elongated cells of  the secondary form above
specified, course around circular gaps in which are impacted a brood of
younger nucleated cells,   either spherical, or,  when  very numerous,
mutually compressed into polygonal shapes.
  In the larynx, this formation  constitutes the out-growths denominated
Dy  Albers warty,  laryngeal tumors; many  lax, succulent,  seemingly
fibrous, for the most part  very  sensitive, integumental, and subintegu-
mental warts,  a large  proportion of cancers of the lip, scrotal or chim-
ney-sweeper's cancer, a not uncommon  condyloma-like degeneration of
the  glans penis,  cancer of the external sexual organs in the female, and
especially  of  the  external labia.   Many of  these, more particularly
cancers of the lips, have a seeming glandular  texture determined by the
alveolar type.   From  the  common integument they assail subcutaneous
textures without distinction,—even bone; from mucous membranes, the
submucous textures : at the larynx, the arytenoid cartilages so commonly
that one is induced to believe that the alien substance may in some cases
originate with these.
   Epidermidal cancer ulcerates, in the sequel  of inflammation,  in a form
identical to all appearance with that of the most exquisite cancer.   The
base of the ulcer is invested with a yellowish-white, or a white, cream-
like exudate,  consisting mostly  of lustrous,  reddish nuclei.  Lastly, to
this alien growth  is to be reckoned, without doubt, an ulcer developed
out  of a wart-like, transparent, hardish protuberance, in form thoroughly
identical with  ulcerating  cancer, and not unfrequently  seen  to  attack
aged persons in the face.   The  base and edges  of this ulcer  consist of
round, lustrous, reddish  nuclei  in  an  amorphous  bond-mass,  and  the
white, creamy exudate investing the ulcer reveals the same composition.
It represents embryonic stages of epithelial cancer.  Certain epidermidal
 cancers of the lip are similarly constituted. 
CARCINOMA FASCICULATUM.
219
                     CARCINOMA FASCICULATUM.

                         (Johannes Miiller.)

   Formerly termed, also  by Johannes Miiller, carcinoma hyalinum, be-
cause of its jelly-like transparency.  An alien growth, according to our
observation, of very rare occurrence, which we have met with but twice;
once in the mammary  gland, and  once again in most  of  the  internal
organs simultaneously, as almost general cancer.
   The first case, which we had better means of examining,  relates  to a
growth of considerable size, nearly  that of an infant's head, of uneven,
clavate  surface, of a pale-yellow color, of jelly-like transparency, and
withal, of notable compactness.   It consisted of an aggregate of tubera,
which resolved themselves into a certain number of cones, flat-sided from
reciprocal  compression, with their  notched  and ruffled bases  directed
outwardly, and their apices pointing to within, so that the  apices of all
the cones constituting  a tuber converged to a common centre.   The  in-
tersection  between  the individual  tubers was occupied by a somewhat
more substantial,—that between the cones by a more delicate,—membra-
nous, whitish, areolar tissue-like bond-mass.  Bloodvessels, so far as they
could be traced in a not highly  injected  condition, ran in a direction
parallel  to the cones.   A microscopic examination  showed the paren-
chyma to consist of somewhat long-drawn, delicate,  hyaline  fibres, be-
tween which, in an almost  limpid juice, lay imbedded elementary granules,
nuclei, and a few scattered, elongated  cells.
   Without conforming to Miiller's description  in what  concerns the
presence of embryonic elements, this growth accords with  it, neverthe-
less, so fully in  other respects, as to justify us in pronouncing it to  be a
true specimen of carcinoma fasciculatum or hyalinum.
   In the  other  case, the secondary arrangement  of the large conical
fasciculi  was less orderly, and, throughout, that before depicted, the con-
sistence more lax, the transparency the same.   This latter,  according
to Miiller, is inconstant, and it was for  this reason  that he afterwards
substituted for carcinoma hyalinum, the appellation of carcinoma fasci-
culatum.
   The specimens examined by  Johannes Miiller  were of a consistency
analogous to  that  of  encephaloid.  He  admits, however,  that in  this
respect variations may  occur, and  that  firmer specimens  of carcinoma
fasciculatum are probably to be met with.

                         CYSTO-CARCINOM^A.
   Cysto-carcinoma specially affects certain organs,  as the ovary, the
mammary gland, the testicles, bones. It is mostly a growth of considera-
ble magnitude, and commonly concurrent with cancer in other organs.
\_See Cyst and Alveolus.~\

                             APPENDIX.
   [A careful examination instituted by the  author in sundry  cancerous
tumors, more especially of the medullary character, have led to interest-
ing results illustrative of the development and the microscopic structure 
220
CANCER.
of these malignant growths.  Without dragging the reader through the
details of cases which seem only to represent so many stages of develop-
ment,—so many links in the  chain of evidence,—we shall endeavor to
sum up the results in as few words as possible.
  Under a magnifying power of 90 diameters, the substance of fungus
haematodes exhibits a stroma  consisting  of two distinct webs,  which
appear to interlace each other in all directions.   Of these, the one has
the semblance of a transparent trelliswork, studded with caudate  cells,
elongate  nuclei, and long-drawn fibres, all lying  parallel to the longitu-
dinal axis of the stroma.   The  gaps  or meshes of this stroma are inter-
laced or enwreathed with what  at first appears like a continuous garland
of leaves, but on a closer inspection is seen to terminate in bulb-shaped
extremities.  Further  examination shows this wreath-like tissue, which
at first seemed  opaque and granular, to be studded with crowds of minute
nucleated cells, which, under a magnifying power of 400, are distinctly
set  forth as round or oval cells, many, although not all, containing one or
several nuclei, others engaged in the act of  elongation, others again in
progress  of dissilience.
  In preparations representing a further stage of development, the wreath-
like tissue presents certain patches much less opaque, its  cells for the
most part elongated, and many of its nuclei drawTn out into disconnected
fibres.   There is  good reason for regarding this portion as in a state of
transition from the wreath-like tissue to the  supporting stroma first  de-
scribed.  In the next, and last, phase of development, is represented the
same  trelliswork,  no  longer thinly fibred  and  semitransparent, but
rendered opaque by connected and dense longitudinal fibrillation.  These
fibred  trellises are here distinctly seen to  be  enveloped in a hyaline
structureless membrane, not closely fitting, but loose and  projecting on
all  sides into the fenestrate gaps in  conical and bulb-like  excrescences.
It is remarkable,  that from  the first period of their  fibrillation,  these
trellis  branches are observed to constitute hollow  cylinders.   This may
be owing either to a single  cell-layer being alone present within the
excrescences, or  else to the fact, that  of a cell-mass with  which the
excrescence is replete, only one layer becomes  fibrillated and the rest
absorbed.
  Although the proof is difficult, there is good reason for believing that
the hollow  cylinders referred to are filled with the  same cancerous  sub-
stance that furnishes the outer  material for the excrescences.
  Certain  external  features, analogous with the above, induced Roki-
tansky to submit to a close investigation those adventitious  membranes
upon serous tunics, which  present, with a  honeycombed aspect,  a free-
villous surface.  The process of development resembles that of the cancerous
growths, only that in these pseudo-membranous  formations the wreath-
like tissue more frequently occurs in layers parallel to the gaps or open
spaces of the primitive fenestrate layer, or in superimposed  order and
sometimes in thick masses, tufted with many prominent,  short-necked,
terminal bulbs.   It will be seen, from Rokitansky's  great  " Essay on
Diseases of the Arteries,"  that the intra-arterial, superimposed layers of
coagula  present  very nearly the same  structural development.    (See
"Die Entwickelung der Krebsgeriiste," from the "Sitzungsberichtie der 
CANCER.
221
math-naturw.  Classe der Kais. Akademie der Wissenschaften,"  Marz,
1852.)
  In a subsequent essay on villous cancer (April, 1852), and a  third on
colloid cancer (July, 1852), Rokitansky has made it apparent that, with
certain modifications contingent upon the general conformation of the
tumors and upon the nature of their contents, the same general relations
of structure pertain  to these cancers likewise.
   In the  colloid cancer there is a similar  formation of a multilocular
stroma, which, however, often assumes rather a membranous fabric. This
honeycombed  structure contains within its cancelli, the colloid or gelati-
nous mass, which is for  the  most part connected together, so as in a
manner to interlace  with the said  stroma, and only  here and  there to
occur in shut sacs or cystoids, formed through the blending of  the mem-
branous framework.  Rokitansky has obtained  evidence, that from the
walls of these shut spaces, bulbous  forms arise,  and that the colloid
globulus are formed within these,  as  the product of a hyaline blastema
with which they are more or less replete.  He seems to infer that the
fibro-membranous stroma is  itself but a development out of primitive
hollow bulbs.
   There  is in  this theory respecting the  aforesaid formation of the
encysted masses of colloid, a  general withdrawal by the author of one
opinion expressed  in the section on cysts, namely, that in these  new
growths the cyst is invariably developed out of the structureless vesicle.
The term cystoid would  therefore be peculiarly applicable to the mem-
branaceous cavities  found in colloid cancer, as distinguishing them from
genuine cysts.

   Villous Cancer.—In all but its external form, this cancer approaches
the  nearest to  medullary carcinoma.  A very  important part is here
assigned to the dendritic  excrescences, into which the  primitive hollow
bulbs, often springing from a densely reticulate  germ, speedily resolve
themselves; the  first  shoots  pushing forth from their  terminal bulbs
secondary offshoots in  the shape of slender villi, which themselves expand
into bulbs, and throw  out more of these embryonic excrescences from
their termination, so as to constitute  by degrees  a more  or less extensive
cauliflower- or coral-shaped tumor.  In other cases, a single stem arises
out  of a nucleus as  big, it may be, as a bean, and this stem branches out
into dendritic vegetations of the character above  described.
   Most of these excrescences end  in caecal sacs,  some of which may  con-
tain a structureless,  or a concentrically stratified  cyst.
   These excrescences  are  often transparent; containing in their  cavity
only a clear fluid, whilst,  externally, they  grow up, as it were, into a
more or less tenacious plastic mass, consisting of the same elements  that
compose the sap of medullary cancer.  In other  instances, they include
a fibrous texture, within which reside elements similar to those that cling
to them externally.   A remarkable circumstance connected with these
excrescences is the  peculiar way in which they are vascularized.   Both
the stem of the tumor and all its  individual excrescences  are  furnished
with an ascending and descending bloodvessel, which pursues its  course
under the formation of frequent loops. These bloodvessels consist mostly 
000
CANCER.
of the primitive  hyaline bloodvessel membrane,  marked with oblong
nuclei, sometimes also with a row of transverse oval nuclei.  There may
possibly be a further layer of connective  tissue fibrils.  A few of the
excrescences have but a single ascending  bloodvessel,  terminating  in a
sort of bulb.
  In  rare instances, a nest of apparent excrescences displays open ter-
minations fringed with villi, and  filled with the semifluid materials of
medullary cancer.  Rokitansky is, however, of opinion,  that  these are
not true excrescences,  but  rather lengthy developments of  the  fibro-
cellular texture which constitutes the base of the tumor;  and he believes
these hollow cylinders, which seem rather to resemble the honeycomb of
the wasp, to  become filled, not by endogenous secretion, but by suction
of the external medullary fluid.
  Seat of  Villous Cancer.—Its seat is  more especially upon mucous
membranes, and most of all that of the male urinary bladder, near the
opening  of either ureter; next to this, the mucous membrane of the
stomach, and in particular the pyloric  portion.  It has been observed
suspended by a pedicle from the internal  membrane of the rectum, and
even  from that of the gall-bladder.
   Secondly, it is very apt to grow extensively from  the  internal wall of
ovarian cysto-carcinoma, where it is recognized as  villous cancer,  from
its copious accompaniment of medullary sap.  In these cases, it is often
concurrent with  cancerous infiltration  of the lymphatic glands,  about
the lumbar vertebrae, and with peritoneal  cancer,—representing villous
cancer upon a serous membrane.
   It  has been  observed upon  the dura  mater, occasionally upon the
general integument (Rokitansky refers to two such cases), and even in
bone,—reckoning for villous cancer those  cases in which  a bony skeleton
is found in the shape of the wasp's honeycomb structure before  described.
   Lastly, it occurs in parenchymata, in the uterus, for example;  and,
as cancer melanodes, in the liver and in the brain.
   It  occurs both as a single tumor, and also  concurrently with cancer
of various kinds in other organs,—occasionally germinating out of those
broad-based, fungus-like gelatinous cancer-masses  that  occur upon the
inner surface of the stomach.
   " The vascularity of villous cancer determines a predominant feature
in its course, whether upon  membranous surfaces, in the  interior of
cysts, or in parenchymata, namely, the frequent hemorrhage  which so
greatly hastens  the general  wasting and  the fatal issue.  Frequent and
excessive hemorrhage  from  the urethra in males, from the  vagina in
females, furnishes strong suspicion of villous cancer affecting respec-
tively the bladder or the uterus, whilst a microscopic examination  of the
blood effused will often bring to light shreds or fragments of the cancer-
ous mass."
   The same vascularity often causes a fleshy coloration of the tumor.
   It is evident from the foregoing, that  villous cancer  is, to all intents
and  purposes, a malignant new growth:  and not, as Andral and Louis
have affirmed, an anomalous  development of muco-membranous  villi;
nor,  as others have more recently suggested, a tumor arising out of the
hypertrophy of a pre-existent papilla.] 
TUBERCLE.
223
                     TUBERCLE.—TUBERCULOSIS.

  The collective term  " tubercle"  is made to embrace sundry forma-
tions, which have nothing in common beyond their outward form.
  Still, after having well sifted this side of the  question, we shall our-
selves feel bound to comprise under "tubercle,"  formations in external
appearance quite  dissimilar to what is commonly called tubercle, never-
theless essentially identical with it; for instance, the primitively yellow,
fibrino-croupous tubercle.
  If we except the rare  instances in which it represents an endogenous
deposition within the circulating system, tubercle is in the  broadest sense
an  exudate—an exudate of solidified protein  substances (fibrin, albu-
men), which as blastema persists at the lowest grade of development;
that is to say,  in the primitive  crude  condition  determined by  its con-
solidation.  It thus occupies the point of transition to the non-organized
new growths.
  This last  attribute  is  essential and indispensable, imparting to solid
blastema the impress of tubercle.  It is so important, that every  blas-
tema, however much its characters may assimilate to tubercle  in other
respects, loses the distinctive  mark the moment it enters upon a trans-
formation of texture.
   This  exudate (in its broadest sense) is for the most part distinguished
by the  tubercle-form;  that is, by its appearance as scattered or col-
lected nodules, or where more copiously produced, by its deposition in
granulations and stellate masses.  It is hereby cognizable at the first
glance.   Still this is open to exceptions.
   Gelatinous and fibrous cancer  appear now and then in a tubercle-like
form; that is, in the form of little discrete nodules or stellate bodies;
and, upon serous membranes, the peritoneum, for example, there occur
granular exudates of  fibroid  and  areolar  tissues.   These  are distin-
guishable from tubercle by their texture.
  But, again,  even  tubercle itself  occurs in extensive, irregular masses.
There are  inflammatory products  endowed  with an indwelling tuber-
culous character, although  manifesting a total absence of the  external
habitudes of tubercle.
   Tubercle has therefore sometimes  a local, but far  more frequently a
general import and  significance.   It is invariably so closely linked with
dyscrasial processes, that,  for a profitable  consideration of tubercle, an
incessant retrospect to the dyscrasial relations is imperatively demanded.
   Nevertheless, the basis and  starting-point for an anatomical inquiry
concerning tubercle itself,  must in our opinion still be  the  aforesaid
fixed blastema abiding at its primitive stage of crudity.
   In this sense  tubercle offers  sundry distinctions, some obvious and
essential, others less marked.   They relate to its  color  and lustre, its
transparence,  its  consistence,  its  elementary  fabric, chemical  compo-
sition,  &c.  These  are characters referable  to  more or less manifest
special crasial relations—modifications of a fundamental tubercle-crasis.
They determine several, and some of them  essential, forms of tubercle, 
224
TUBERCLE.
which we shall proceed at once to portray, selecting for our basis the
purest possible forms.
   (a.) Simple fibrinous  tubercle appears as scattered or stellate conglo-
merations of granules  of about the  size of millet-seeds.  It presents,
moreover,  as the product  of inflammation  upon  serous membranes,
smooth pseudo-membranous exudates, as we often find exemplified upon
the pleura of lungs involved in florid phthisis.
   In the first-known form this tubercle represents the gray semi-trans-
parent granulations of Laennec.
   The  investigations  and  theories hitherto instituted  relate  almost
exclusively to  this tubercle, from  which all other  tubercle-formations
have been derived as from a stereotype basis.
   The question of old—What is tubercle ? must at this day be changed
into—What is this particular tubercle ?
   In its  early stage,  at which acutely generated  tubercle is often
enough to be obtained in the human subject, it appears in the form of
the aforesaid granulation,—to the naked eye a roundish,  resistant, solid
nodule, of about the size of a millet-seed.   Not unfrequently, however,
we encounter amongst them tubercles  somewhat smaller,  and  repre-
senting a less firm, a softer, at the same time more transparent, almost
vesicle-like granule.
   Nevertheless, however much  tubercle may at a first  glance wear  a
vesicular appearance, it invariably originates as a solid  corpuscle; and
the  results of a careful analysis of this substance,  as well as its very
nature and import, serve to  corroborate this fact.
   Minutely examined,  it only  seemingly represents  a spherical  body.
Under a moderate magnifying power,—nay even on a narrow inspection
with  the  naked eye, it is seen at its circumference to branch out more
or less.  With the textures it is only in so far connected as to lodge
betwixt their elementary parts, to take up  some of  these into its sub-
stance,  and—what  is especially discoverable in tubercle upon serous
membranes,—to  adhere to  them  by  dint of  an indwelling tenacious
property.  It represents a tolerably homogeneous—now toughish, gritty,
fibro-granular,  fragile, now softish,  uniformly compressible—substance,
in various shades  and modifications, of a pearly gray  color.
   Under  the microscope it reveals  the following elementary compo-
sition :
   It consists mainly of a more  or  less pellucid base (blastema), which
affords a sort of binding medium for certain form elements.  Its compo-
nents therefore are—
   1.  The said basement-mass,—for the most part a fibro-glebous, gray,
fixed blastema, rendered turgescent and transparent by acetic acid.
   2.  Certain embryonic form-elements, namely:
   (a.) Elementary granules of various magnitude.
   (b.) Nucleus formations,  both  black-contoured, lustrous,  spherical,
even oblong  nuclei,—and more delicate, dull, granulated nuclei, under
various phases.
   (c.) Nucleated  cells; commonly in such small numbers as  to  tempt
one to doubt their occurrence altogether.  Nuclei and cells are often to 
TUBERCLE.
225
a great  extent misshapen, disorderly,  jagged, angular, bulging, dumb-
bell-shaped, rudimental, stunted.
  Along  with this, the tubercle is wont to include various elements
appertaining to the textures in which it nestles.  The tubercle purest in
this respect is that upon serous membranes, which, therefore, like many
other new growths upon serous membranes, is the  best adapted  for  ex-
amination.  Nay, tubercle will even take up and incorporate compound
textural constituents, and in particular  bloodvessels.   The question here
suggested as to tubercle-containing vessels of its own will  be discussed
hereafter.
  The metamorphosis which this tubercle undergoes, is limited to deca-
dence.  After abiding in the primitive, crude condition before described
it becomes transformed, with the loss of its moisture,—with condensation
—to a hard nodule, and shrivels, into a tough, amorphous or indistinctly
fibrous, horn-like mass,—in a word,  cornifies.  This determines a com-
plete  wasting  and death of the tubercle, subversive of all further  change.
Occasionally this process is associated with bony deposition, the tubercle
becoming a partly ossified nodule.
  This tubercle does not  undergo any  other metamorphosis indepen-
dently.  Every other change suffered by it is based upon a combination
of its blastema with another, and its softening in particular, upon a com-
bination with  the  ensuing tubercle, namely,  the fibrino-croupous.  This
softening process  plays so momentous a part in the doctrine of tubercle,
that  we  deem  it right to declare emphatically  our dissent from  the
opinion that gray tubercle, the gray tuberculous granulation of Laennec,
softens.
  Fibrino-Croupous  Tubercle appears  in the shape of roundish nodules,
as also, and that very frequently, of irregular, gibbous, branched masses
of considerable diameter, or, upon free surfaces as gibbo-stellate layers
of various thickness.   The nodules in size often equal the gray tubercle
granulations, still  oftener do they  equal  hemp-seed  or peas.  Usually,
every variety  of size coexists.   The substance of this tubercle is, as  we
may here once for all remark,—opaque from the very first, now resplen-
dent,  in various degrees, yellow,  of fibrous or of granular fracture, firmly
elastic, or friable,  of  a lardaceous, curd-like aspect.   We  distinguish it
from the gray tubercle by  the designation of yellow  tubercle.  It most
probably constitues the pyin-holding tubercle.
  The microscopic examination of this tubercle shows, as in the  case  of
the foregoing one, a fixed base, and the aforesaid  form-elements.  The
former is  a fibro-glebous, or else  an amorphous, opaque blastema. With
respect to  the latter much variety obtains.   The number of  cells, of
nuclei, especially  of  the  dull,  granulated  nuclei,  of the elementary
granules, and especially the quantity  of the finest point-molecule pre-
dominate.
  The metamorphosis  proper to this tubercle  is  softening,  and again
cretefaction.
  1. The first, namely  softening, also  termed suppuration, consists  in
this:  after  the tubercle has  tarried for a certain time in the  above-
described condition of crudity,  it loosens up,—for the most part with
considerable increase of volume, readily breaks asunder through compres-
 VOL. i.                          15 
226
TUBERCLE.
 sion, moistens.   Hereupon it changes into a yellowish,  glutinous, fatty,
 tenacious substance, like melted cheese, and eventually liquefies to a thin,
 whey-like fluid  of acid  reaction, wherein  flocculent and fragmentary
 particles, the  remnants  of tubercle imperfectly  broken  up, float as
 tubercle-pus.
   In the larger tubercle masses there is often  observable,  during the
 said process, a cleft formation on a  large scale; or, where the tubercle
 is spread out in a layer, a Assuring  of this latter.
   With regard to the elementary character of the tubercle at this stage,
 we would observe :
   The softening consists in a liquefaction and breaking  up of the solidi-
 fied base of the tubercle  to a fluid loaded with point-molecule.   This
 transformation results in a separation or isolation  of the form-elements
 of the tubercle,  which at the same time undergo  within the fluid a more
 or  less  marked  change.   Thus, the cells become  turgescent,  corroded,
 dissolved;  the  nuclei  shrivelled and misshapen,   irregularly angular,
 pouched,  &c.   At length free fat  becomes  developed in the softened
 tubercle.
   Hence the liquefied tubercle consists :
   (a.) Of a fluid with point-molecule.
   (b.) Of the  isolated nuclei and cells changed in the manner just now
 specified.
   (c.) Of free fat in the shape of elementary granules and larger scat-
 tered globules.
   The softening determines the malignancy of tubercle, leading as we
 shall  presently see to ulcerous destruction of the textures,—tuberculous
phthisis.
   2.  The other  metamorphosis of this tubercle is cretefaction.  It never
affects the tubercle blastema in  its  primitive  condition,  but only  in its
liquefying or liquefied state.
   During the  softening process, or after its completion,  the tubercle
 takes up lime-salts and fats, in the shape of free, discrete, or aggregated
 elementary molecule, or else in  granule-cells  in  the form  of big  drops
 and of cholesterine crystals.   In this act the  softened  tubercle is pro-
 gressively thickened into a moist,  unctuous chalk-pap,  and eventually
 converted into a concrete mortar.
   Let us now  attempt to institute an inquiry  respecting the nature of
 tubercle, in  its  two cardinal forms, as just delineated  ; whereupon we
will proceed to discuss its varieties,  its metamorphosis, its local process
 of deposition, its seat, and, lastly, its relation to the blood-crasis.
   In the first place,  the  ground-work  of rapidly solidifying tubercle
blastema is, without the least doubt, fibrin.   Again, in the  two cardinal
forms of tubercle, it is  easy to recognize  the two principal  forms of
fibrin, the simple and the croupous (see Fibrin).  Why the former, which
we have elsewhere denominated plastic, enters into  no textural conver-
 sion, why the latter fails to undergo  that prompt liquefaction  proper to
the croupous exudates, are questions which we  shall  endeavor to reply to
in a more appropriate place.
  With reference to the varieties  of these  cardinal forms,  we would
observe— 
TUBERCLE.
227
  (a.) Of  croupous tubercle there occur several varieties,  together  re-
minding us  of  croupous fibrin and its resulting exudates.  They are
determined by opacity, coloration, consistency, tendency to liquefaction,
by  the corrosive property of their  ichor, the proportion of their form-
elements, of their point-molecule,  and  by the  character  and import of
their nucleus and cell-formations.
  (b.) Like blastema in general, tubercle blastema is especially unwont
to exude pure.  The combination of the two cardinal tubercle-blastemata
in different proportions, and their  manifold grades of co-ordination and of
blending;  again, the union of varieties of  croupous tubercle with each
other, and with organizable blastema (fibrin), break up tubercle into
countless varieties.
  In like manner, the  gray tubercle granulation  presents  many varia-
tions in respect  to transparency, coloration, &c, the greenish shade,  for
example.
  A peculiar variety is the pigmental tubercle, for the most part hemor-
rhagic, as to its origin.
  As metamorphoses of tubercle,  we have already been made familiar
with its decadence or  obsolescence, its softening, and  its cretefaction.
The first is proper to  the simply  fibrinous, the last two  to  the  fibrino-
croupous tubercle. These metamorphoses affect tubercle in common with
consolidated blastemata of a certain constitution, whether they occur as
exudates (even  as extravasate1) external to  the vascular system, or as
endogenous  coagula within the bloodvessels.   Their cause is primitively
inherent in the tubercle, conformably with our view respecting the pri-
mordial properties of blastemata.
   1. The  obsolescence of tubercle, hitherto disregarded, is cosignificant
with its cornification.   It implies wasting,  extinction of the tubercle.
   2. Softening of tubercle, a metamorphosis which it enters upon with-
out distinction of volume—resolves itself into that elementary phenome-
non, the breaking down of  solidified protein substances, and especially of
solidified fibrin,—a phenomenon  pertaining to this substance only  in its
determinate  croupous constitution.  It  is  proper to  fibrino-croupous
tubercle alone, and is determined by a conversion of the chemical com-
ponents arising out of an interchange of the elements.
   Genuine gray tubercle-granulation  never softens.  A combination of
its  blastema with that of fibrino-croupous tubercle alone capacitates it for
softening.   It was, indeed, formerly taught, that gray tubercle-granula-
tion lost its gloss, its  transparency, became opaque, of a yellowish-white
or yellow,  and ultimately softened and deliquesced.   The error probably
arose  from a readiness, in  the frequent cases where the two forms of
tubercle are concurrent and even now and then mingle together into  a
kind of transition  link from the  one to the other, to take for granted
that they represented in reality two different stages of development.
   We have,  however,  a second error to rectify besides.  Long ago the
softening of tubercle  was  described as a development,—a progressive
metamorphosis,—but  in general  and not very  lucid  terms.  Present

  1 The term " extravasate" is used by German pathologists in a restricted sense only, namely,
to signify the effusion of substantive blood, with  blood-globules, into surrounding textures,—
in other words, internal hemorrhage from ruptured or wounded bloodvessels. 
228
TUBERCLE.
pathology, whilst adopting the older  views  concerning the softening of
tubercle, is influenced by the microscopic discovery of an incomparably
greater number of nuclei, and  especially of cells, in softened than in
gray tubercle.   They are looked  upon  as  new  formations  out  of the
liquefied tubercle blastema.
  We cannot participate in this view.   Those elements are not recently
generated out of the liquefied blastema, but proper to the tubercle from
the commencement, and isolated by the softening process. _ That they
are more  numerous in  softened  tubercle than in the  gray,  is explained
by the fact, that only that tubercle softens  which originally holds them
in abundance, namely,  the yellow (croupous) form.
  In point of fact, no fluid  is less adapted  to furnish the blastema for
new growth than the so-called pus of tubercle.  The softening of tubercle
takes place sometimes  early, sometimes late,—rapidly,  or by slow de-
grees.   All this depends  upon certain  peculiarities in the  character of
the (croupous) tubercle.  In  this  process it is worthy of note,  that in
tubercle masses  deposited all at once, the softening  proceeds  from the
central  part; whereas, in aggregate masses thrown out  at  different
epochs, and perhaps embracing different forms of tubercle, the softening
may commence at any  part,—even at  the  periphery.   This  fact is
fraught with interest, as corresponding with kindred processes in  certain
other morbid products,—for  example, the central softening  in globular
endocardial  vegetations,—in intra-arterial  coagula-layers,  &c.  More-
over, it is important as offering—if at this time of day it be wanting—a
conclusive argument against the assumption of the softening of tubercle
being a process evoked from without through the agency of surrounding
textures.  The utter absence, in tubercle, of bloodvessels of its own, the
compression and closure affecting  such as penetrate the larger tubercle
masses from  without,—the fact that in textures surrounding tubercle
engaged in incipient softening no trace  of inflammation is generally dis-
coverable,—that both  the latter and suppuration supervene only upon
completed softening of the tubercle,—lastly, the ocular proof that the
softening commences at the point most remote from surrounding textures,
are so many arguments  against the  assumption referred to, and espe-
cially against that of a mechanical melting down of the tubercle, through
pus thrown out from the inflamed encircling textures.
   The  sum of  these negations is, that the softening is a spontaneous
metamorphosis essentially proper to the nature of tubercle.
   The softening is that which constitutes (yellow) tubercle a malignant
growth,  inasmuch as it commonly leads to  that ulcerous destruction of
the textures which represents tuberculous phthisis.
   The complete solution of a tubercle determines in the implicated par-
enchyma, a gap, generally corresponding  to the  tubercle in size,  replete
with so-called tubercle-pus.   The parenchyma has suffered a loss  of sub-
stance to the extent only of  the texture particles which happen to have
been involved in the tubercle, and have now perished in the tubercle-pus.
This  gap represents the primitive  tuberculous  cavity within a  paren-
chyma.   The contact of the tubercle-pus with the surrounding textures,
occasions a corrosion of the  latter.   The moderate enlargement of the
primitive cavity thus engendered, is  substituted, upon membranous ex- 
TUBERCLE.
229
pansions, the  mucous coats for instance, by a deepening destruction of
the tissues ; that is, of the inner stratum of the mucous membrane.  This
manifests itself  as a millet- or hemp-seed-sized ulcer,  which,  to  distin-
guish it  from the  different form arising from consecutive  enlargement,
has been designated as the primitive tubercle-ulcer.
   The consumption of textures  would here  remain inconsiderable, but
for the breaking down of fresh tubercle in the proximity of the original
ulcer.   Inflammation here plays an important part.
   (a.) This production of fresh tubercle in  the vicinity of that softened,
and of the resulting primitive cavity,—at  the  margin and base of the
primitive  tubercle-ulcer,  upon superficial expansions,—determines  the
enlargement of  the ulcer in all directions,—the textures becoming again
and again  corroded and necrosed by the fresh softening tubercle.   And
this takes  place with a rapidity proportionate to that of the softening of
the secondary tubercle—the product of an exalted cachexia.   Another
accidental mode of enlargement of the  ulcer  consists in two or more
ulcers, already advanced in the way described beyond the primitive con-
dition, merging in a single one.   The  result is an  ulcer marked by its
irregular,  indented form,—upon mucous membranes, by serrate, jagged
edges,—in muco-membranous canals by its  affecting the girdle  shape.
The manner of its development, and its characteristic form, so different,
especially on mucous membranes, from that of the primitive ulcer, fairly
entitle it to the appellation of secondary tubercle  ulcer.
   The destruction of  textures involved in this process, as corrosion and
necrosis through contact with tubercle-pus, constitutes the tuberculous
phthisis of organs.   These are either acute or chronic.
   (b.) Inflammation enters, as we shall see by and by, into various re-
lations to the phthisical process.   What we have here, however, particu-
larly to  remark upon  is in how far it contributes to the enlargement of
the tubercle-ulcer and  to the modification of its character.  In the first
place, it determines, for the most  part, yellow tuberculous products, in
the  form  of infiltration,  which,  conformably  with the  aggravated
dyscrasis,  rapidly  break up, extensively corroding  and destroying the
textures involved.  In this way inflammatory action occasions an  omi-
nous enlargement of the tuberculous ulcer, and the  most widely  spread
tuberculous ulceration in an acute form.
   In the second place it engenders organizable,  solidiflable,  fibrino- or
albumino-gelatinous products, which pass  into a fibroid callus.   Thus
arises the  callous condensation of the textures encircling the cavity; in
the  muco-membranous tubercle-ulcer (for  example, in the bowel)  the
hardish elevated brink and the funnel-shape of the primitive'; lastly, the
jelly-like infiltration and induration at the base and margin of the secon-
dary ulcer.
   These products exude,  according to circumstances, either  pure,  or
almost pure, or  combined  together in various proportions.   In worn-out
individuals, the inflammation, if present  at all,  furnishes forth thin,
albumino-serous products, and the tubercle-ulcer  is of a lax and torpid
character.   In  the proximity of  cavities seated in the midst of tubercu-
lous infiltration, there  is of course no inflammation.
   3.  Cretefaction,  as already stated,  affects fibrino-croupous tubercle 
230
TUBERCLE.
after it has entered into the softening process.  It is co-significant with
the cretefaction of fluid blastemata, and analogous with the cretefaction
of broken-down fibrin in the vegetations and coagula within the vascular
system, in croupous exudates upon serous membranes, and in parenchy-
mata ;  and again in the cretefaction of pus.
   The basis of this  (secondary) metamorphosis is  as little to be sought
extraneously to tubercle  as the  softening itself.   Nevertheless, the sur-
rounding textures may contribute, by their  absorbing agency,  to the in-
spissation of  tubercle-blastema.   What cornification is  to  the gray,
cretefaction is to the yelloiv tubercle, namely a process of involution.
   Cretefied tubercle resides, for  the most part, within textures isolated
by products of inflammation, entering into  a fibroid transformation and
then cornifying and  shrivelling  into a callous capsule.   Both together
draw down upon themselves the surrounding textures in scar-like corru-
gations.
   Such are the metamorphoses of genuine tubercle of  the one and the
other  form.   There  occuj, however, complicated  metamorphoses cor-
responding to  various combinations  of the different tubercle-blastema.
Thus:
   (a.)  The combination of gray with yellow  tubercle is frequent.  Where,
in this combination, the latter passes into  softening, the gray tubercle,
like textures in contact with  tubercle-pus,  becomes destroyed.  Where
the softened yellow  tubercle  cretefies before  this destruction of the
gray is effected, the latter corniAes independently ; and if it happen to
be peripherous to the other it  encircles the creteAed  tubercle with a
sheath of gray corniAed  tubercle, differing from  that  callous exudate-
capsule which results from inflammation of the surrounding textures.
   (b.)  Just as tubercle blastemata combine  with one another, so, in like
manner, does  organizable blastema enter occasionally into combination
with tubercle.   Its existence is of course scarcely demonstrable in yellow
tubercle, in the metamorphosis of which it becomes itself destroyed.   If
cretefaction set in early, it may become organized so as not to be easily
distinguished from  a subsequently effused  blastema, the product of in-
flammation.
   The combination of gray tubercle with organizable fibrin is  more sus-
ceptible  of proof.  The  instances  are not  rare  in which, hard by pure
gray tubercle,  granulations are found in which one portion of their blas-
tema is in progress of organization to a fibrous texture, whilst the other
abides in its  primitive condition, and eventually falls into decadence—
cornifies.
   There ar_e, indeed, as we  shall presently have  to show, granular tu-
bercles resulting from inflammation  upon serous membranes,—that  is,
solidifying exudates  or  granulations as  big as poppy-seeds or millet-
grains, which in their entirety change into fibroid textures—into areolar
tissue.   They occur, along with  blastemata, consolidated into  pseudo-
membranous areolar tissue, or along with  gray tubercle, or even with
both gray and yellow, softening tubercle.
   The organizing of these granulations consists in the development of a
more  or less determinate fibrous texture.   They  acquire  the whiteness,
the resiliency and elasticity, the fibrous-torn surface, the general charac- 
TUBERCLE.
231
ters of little fibrous tumors ; or else they change into velvet- or felt-like
fasciculi of connective tissue.
   They  are  found upon the  peritoneum,  especially of the liver and
spleen, as  also  occasionally upon other serous membranes.   The Pac-
chionian granulations upon  the arachnoid, the granulations upon the
investment of the ventricles of the brain, are upon the whole of the same
character.
   It  is intelligible, from hence, in  how far, and in what sense, we are
warranted  in speaking of a textural conversion, an organization of tu-
bercle,  as  a metamorphosis  of this  alien  growth.  It is intelligible,
namely,  that growths, whatever resemblance they may bear to tubercle,
lose their  import  as such, in other words, reveal their  non-tuberculous
character,  with  the slightest textural conversion.
   Intimately connected with the above is the question as to whether tu-
bercle contains  bloodvessels of  its  own?   The  question  may belong
rather to a bygone day.  It is for the present day, however, to set this
point at rest for all time !                  9
   Vascularity, in  truth, belongs as little  to the nature of tubercle  as
organization itself.   Still it is undeniable that bloodvessels are sometimes
met with in  tubercles.  Two cases  are here possible.   In  the  first case
bloodvessels may appertain to textures which,  whether normal or patho-
logical,—membranaceous  areolar tissue, for instance,—had become in-
volved in the tubercle when first thrown out.  One  or more bloodvessels
may  traverse the  tubercle, previous to an injecting mass,—others im-
permeable.
   In the other  case the bloodvessels penetrating the tubercle are doubt-
less new-formed vessels, and have sprung from  an organizable blastema,
effused  together with the tubercle and incorporated in it.  This is at-
tested more especially upon serous membranes, where, as a consequence
of  inflammation, tubercle becomes deposited along with a considerable
portion of  blastema, the rudiment of vascularized new textures.
   To sum  up :  the purer the tubercle, the more certain is  its estrange-
ment  from all  bloodvessel formation.  The less pure, that is, the more
organizable blastema it  has incorporated, or consociated with, the more
susceptible is it  of bloodvessel formation.
   We have hitherto  spoken of tubercle as being an exudate,—a secre-
tion from  the vascular  system; of which we hardly deem it  requisite
to furnish  proofs.   Here, however, a  double  question  suggests itself,
namely, first, concerning the seat of tubercle ; and, secondly, concerning
a very weighty point, namely,  the local process of tubercle production.
   The seat of tubercle, as exudate, is at any point of any texture, extra-
neous to the bloodvessels.  Wherever there is a capillary range,  a de-
position of tubercle is possible.  The  seat  of  tubercle is without doubt
precisely, or at least in close proximity to, the spot of its exudation, its
blastema being in  the highest degree coagulable.   It is most probably
for this reason that it does not affect textures nourished from a distance
by  a slow imbibition of their substance with plasma,—for example, car-
tilage.  We  can ourselves testify to  the  occurrence,  both in larger
bloodvessels and in the capillaries (as  depots or metastases), of coagula
obviously of a  tuberculous nature.   These are,  however, only excep- 
232
TUBERCLE.
tional cases, and the doctrine  propounded  in  accordance with them  is
founded rather upon the results of so-called  tubercle created by artificial
injection.   It is evident, however, that the tubercle-like depots so formed
were due either to infection of  the blood, or to  the obstruction  of blood-
vessels, and  that no inference  can  be drawn from them  as to  the spon-
taneous formation of tubercle.
  Assuming, therefore, tubercle to be an exudate—an effusion out of the
vascular system—the question  as  to the  topical process would  resolve
itself into this :  what  are  the processes in whose  sequel tubercle  is
thrown  off from the circulation ?   To this we  can only reply, that tu-
bercle, like  other blastemata, exudes, now almost insensibly in  the act
of nutrition; then, again, in the sequel to obvious (active) hyperaemia;
and lastly, as a consequence of still more manifest inflammation.
  1. It is a fact that the incipient production  of tubercle takes place,
within some organ,—most  commonly the lung, and at one particular
portion of it, the point de depart,  so to term it, of tuberculosis,—in a
manner almost imperceptible both  to the patient and to the looker-on.
The after-death examination reveals  no  inflammation, or such  only as
may with  far greater  probability  be  interpreted as consecutive.   The
tubercle is for the most part the gray, withering, and only now and then
the yellow, softening, cretefying tubercle.  '
  2. In other cases, on the  contrary, a marked  hyperaemia of the impli-
cated organs manifests itself during life, and is discoverable after death,
as the source of the  tuberculous exudation.  The tubercle is deposited
numerously,  and also rapidly.
  (a.)  This tubercle has commonly the form of  those scattered granula-
tions, of about  the size of millet-seeds, and seldom that of yellow hemp-
seed- or pea-sized nodules.
  (b.) Its blastema is  commonly that of the gray tubercle, often com-
bined with that of the yellow ;  rarely the yellow alone.
  (c.) Not only is it thrown out rapidly and in great numbers,  either all
at once, or in successive outbreaks repeated at short intervals ; but it
scarcely ever restricts  itself to a  single organ, and whilst seemingly
perhaps concentrating its main forces upon  some one organ,  it  assails
several others simultaneously, often leaving hardly any of the soft  paren-
chymata unscathed.  The tubercles  are  marked by their uniform  size
and character,  and by the equable distribution with which they are scat-
tered throughout the textures.  After their repeated and copious  exu-
dation,  they gradually  become less firm,  softer,  glutinous, until the
fibrinous tubercle—the fibrin being expended—changes into the albu-
minous tubercle.
  (d.)  The effusion of the  tubercle as a coagulable blastema is always
associated with that of a non-coagulable or less  coagulable, serous, sero-
albuminous, jelly-like, adhesive product,—as a  sort of vehicle for the
first.   The textures are manifestly congested ;  and, around the  tuber-
cles, more or less uniformly infiltrated with  the  product just referred to.
  (e.) The  more generally and  more rapidly the tubercle-production
extends through the organism, the greater  the multitude of tubercles,
the more marked those  dyscrasial appearances wrought by  defibrination
of the blood,—by so much the more fully does the general disease partake 
TUBERCLE.
233
of the acute  character.  As the expression of that defibrination, the
blood appears thin and watery, the attenuated blood-serum, tinged with
appropriated haematin, being thrown out upon and coloring the  imbibed
textures, which, if highly vascular, appear lax, flabby, and drenched.
  (/.) As  this  tuberculosis  for the  most part proves quickly fatal, a
metamorphosis of the tubercle is proportionately seldom observable.
  (g.) Rare instances excepted, this tubercle is not  the  primitive one.
Tubercle has commonly pre-existed, whether in an advanced state,  or
retrograding to decadence, in  some organ  or other; for instance, the
lungs or the lymphatic glands.
  3.  In fine, tubercle is frequently thrown out in  the sequel of inflam-
mation.  It is the product of such inflammation, and  its sole distinguish-
ing feature.   These inflammations  occur in  every  part,  but  more par-
ticularly upon mucous membranes,  and in the larger  serous sacs,  where
they may be most advantageously studied.  Thus they are  seen especially
upon the peritoneum and pericardium, and again upon the mucous mem-
brane of the uterus, of the tubae, and of  other ducts, as the vas deferens,
the seminal vesicles, the ureters.   They  very frequently affect glandular
hollow formations—the pulmonary  cells, as pneumonia, the follicles of
the intestinal mucous membrane,—almost equally often the parenchyma
of the lymphatic glands, fungoid bones or sections  of  bones, &c.
   The exudate offers in  regard to  its so-called  tuberculization, certain
points of interest, as observed most particularly  upon serous tunics.
   (a.) In the first place, only a portion  of the entire  exudate appears as
tubercle, whilst the remainder becomes gradually reabsorbed and  disap-
pears.  Or else this latter changes into a texture,—to  areolar tissue, to a
fibroid vascularized texture, often to a redundantly vascular, Abro-cellular
new growth, or to a spurious membrane of similar structure.  The two allot-
ments may be present in very different quantitative proportions, the one
or  the other predominating in various measure.  The  more  texture-
formation prevails,  the more  does the tuberculizing portion take the form
of scattered  miliary granulations, up to more  voluminous nodules im-
bedded in the  organized new growth.  The more scant  the textural forma-
tion, the more prone is the tuberculizing portion to represent a confluent,
uniform, granulating, stellate, clavate  tubercle-mass or layer.
  The tubercularizing new growths, as vascularized pseudo-membranes,
often become themselves the  seat of inflammation, for the most part pro-
ductive of hemorrhagic exudates of a tuberculous nature.
  (b.) In the  second case, the entire solid exudate,  remarkable for its
bulk, is tubercle; or the organizable portion is  imperceptibly  small,
and disappears.   It forms in considerable,  irregular,  shapeless  masses;
or, on membranous expansions, smooth, or stellate, stella-clavate layers.
  The tubercle thrown out as a consequence of inflammation, is the gray,
or it may be the yellow, or again a combination of both.  The flbrino-
croupous yellow tubercle is especially often the product of inflammation,
and especially marked by its abundance.  It occurs everywhere, consti-
tuting,  upon  membranous formations,  the  aforesaid  stellate  layers;
within muco-membranous canals and cavities of inconsiderable calibre, as,
for  example,  the uterus, the tubae,  the seminal  vesicles,—thoroughly 
234
TUBERCLE.
closing  plugs;  in compact  parenchymata,—lesser or greater,  roundish
or irregular knobs; in the lung-cells and in follicles,—smaller coagula.
  Tubercle  produced by  inflammation generally passes speedily into
softening, and thus to a phthisis of the textures, marked by the acuteness
of its course; and,  as  pneumonic tubercle  inflltration, by  the jagged,
eroded look of the cavities ;  lastly, by the not  unfrequent supervention
of pulmonary gangrene.
  Inflammatory tuberculosis, like the foregoing  species, is rarely primary.
It generally accedes  to  antecedent,  insensibly generated tubercle, in-
vading either the organ already diseased, or a structure  intimately con-
nected  with it.  Thus pneumonic  tubercle and tuberculous pleurisy
associate themselves to pulmonary phthisis; tuberculous peritonitis,  to
abdominal tuberculosis of the  lymphatic glands.  Or else tuberculoses
become consecutively developed  according to  the same scheme,  each
fresh one  bearing more and more decidedly the impress of its inflamma-
tory origin.
  The ordinary succession  of the different fibrin-tubercles,  and their
different modes of exudation, partly deducible from the  preceding state-
ments, are highly interesting.   Generally speaking, the gray  tubercle,
insensibly effused into an organ, leads the way.   The yellow tubercle is
less frequently  the primitive one.  Nor is the hyperaemic or the inflam-
matory oftener the  primary source of the effusion in either case.   Upon
the  primitive, insensible  deposition  of gray tubercle follows, with in-
creasing dyscrasis, the exudation of combined gray and yellow  tubercle,
the  yelloAv  progressively assuming  the ascendant, until it ultimately
exudes alone.   Step by step the  exudatory process becomes  more and
more acute  in  character; hyperaemia, inflammation, and, at the same
time, the quantity of tubercle thrown out, more and more pronounced.
  Under certain conditions there exudes, in the sequel of inflammation,
more particularly in  a new growth  naturally  prone to  tuberculization
(pseudo-membranes upon  serous  tunics), a  tubercle reddened  and pig-
mented by adherent haematin and embodied blood-corpuscles.   It might
be suitably denominated the pigmented or hemorrhagic tubercle.
  The increment  of  tubercle, as a  consolidated,  non-vascular exudate
abiding in  its  rude, primitive condition, can  only take  place through
adjacency and  blending with  a mass recently  exuded in its immediate
vicinity.  It is doubtless thus  that many bulky, lobulated, stellate masses
have become aggregated out of individual tubercles, dating from various
periods.
  But, whereupon does it depend that the product of the said processes,
and, in particular, that the product of inflammation,  in  other  cases re-
absorbed  or transformed into textures, is here precisely tubercle ?
   We do not consider the standing explanation of this  phenomenon,
namely, of  the  persistence  of the exudate in its  primitive rude state,
satisfactory.  It is to this effect:
   (a.) The lack of an adequate vitalizing  influence in  the surrounding
textures,  and in the entire organism, upon  the  exudate (blastema).  To
this, it may be objected that the  tubercle-blastema remains crude, how-
ever scanty its proportion, and however unimpaired the  energies of the
surrounding textures and  of the entire organism.  On the other side, we 
TUBERCLE.
235
find in the vicinity  of  diseased parts, and  this in persons altogether
debilitated and cachectic, bulky  blastemata forming into textures  both
homoeoplastic and heteroplastic; even into  textures whose development
is, generally speaking, very easily arrested; for example, bone-callus in
individuals affected with osteo-malacia, cicatrix in, and in the proximity
of, ulcerating textures.   We might with  propriety  ask,  wherefore  does
not the portion of an exudate farthest removed from the  living textures
and their influence,—wherefore, for example, in exudates upon  membra-
nous expansions, does not an entire layer uniformly,—why, in the midst
of exudates, do only little scattered portions abide crude, that  is tuber-
culize, whilst the remaining major part of the exudate becomes developed
into textures ?
   (b.)  The  lack  of sufficient moisture,  of water,  in  the  blastema, is
alleged as the condition  upon which tuberculization depends.
   To this we reply that  tubercle-blastema exudes under all  conditions,
and, not at all rarely, with  a considerable amount of water, of blood-
serum.  A primitive lack of moisture in the entire exudate cannot there-
fore determine the tuberculization, the tuberculous nature, of its coagu-
lable,  solidifying portion.  If perfected tubercle be poor in water,  it is
so obviously in consequence of the high degree of solidification of its
blastema.   This,  therefore, namely,  its  high  degree  of coagulability,
might be the cause of the tuberculous nature of the exudate,—of its per-
sistence at its primitive stage of crudity.   This,  again, might be the
reason why the tuberculous exudate takes the form  of granulation.   In-
flammatory  products, like  blastemata  generally,  seldom  exude pure.
Inflammatory products of a tuberculous nature are, therefore, ordinarily
alloyed with others of a  different kind.  Hence, portions of  the  former
emerging, by reason of their transcendent coagulability, from their com-
binations with the latter, appear to  the  eye in  the shape of  roundish
coagula, in a word, of tubercle.
   But, again, it will be necessary to ask,  whereupon does this high grade
of coagulability depend ?
   It can but be founded in an as yet unknown dyscrasial constitution of
the fibrin, as tubercle-blastema.  There  are blastemata dry from primi-
tive poverty in serum ; and also others which, parting  with their serum
and passing into  a  high  degree of  condensation, nevertheless  do not
tuberculize, but become developed into textures, in the plenitude of their
mass.   It would  appear evident, therefore, that the tuberculous nature
of a blastema must be indwelling, be acquired either during the local
process (inflammation)  or  in the general blood-disease which preceded
and prepared  its  exudation.   Accordingly, tubercle would, as  once be-
fore stated, have  to  be  interpreted, now  as a  local, now as a  general
affection.
  This general character of tubercle is the more marked in proportion as
its  mass as an  exudate is considerable;  as its diffusion through the
organism is extensive ; as its characters  are  impressed upon any spon-
taneous  coagula  formed within the  vascular  system; and, lastly,  as
the organism in its totality reflects and manifests the tuberculous  habit.
  Let  us now, as a sequel to the foregoing, discourse respecting  that
anomaly of the crasis upon which tubercle is based.  With a  view, how- 
236
TUBERCLE.
ever, to establish a suitable groundwork for the exposition of the tubercle
crasis, we would  first add a  few supplementary remarks  concerning
tubercle itself.
   The tubercle crasis is, without doubt, a fibrin-crasis—fibrinosis.   It is
not this in respect to quantity alone—hyperinosis—but also, and this is
the more  important  side of the anomaly, in  respect to quality.  This is
clear even from that varied constitution of tubercle upon which we  have
founded  our classification of  fibrin-tubercle.  Besides this, the  fibrin
must have become impaired in a  particular way, in order  to  qualify the
tubercle, which, in  the one case, as  simply fibrinous,  cornifies; in the
other case, as fibrino-croupous, does not undergo the rapid process of dis-
solution (puriform liquefaction) proper to croupous  Abrin.
   This peculiar vitiation of the Abrin may itself become somewhat modi-
fied, or admit of some accessory impairment.  And this may operate as
the cause  of many differences in tubercle, recognized to this day only by
deviating  physical  properties; those,  for  instance,  of coloration  and
lustre, of  consistence, external  form, mode of aggregation of the granu-
lations,  &c.   Thus,  the gray  tubercle-granulation is   distinguished at
times by its dingy bluish coloration, by a grayish lustre, by its aggrega-
tion in sharply defined spheres thinly scattered  through the  pulmonary
texture;  the  yellow tubercle  by a  lardaceous  aspect.  The croupous
tubercle effused into the lung during the inflammation and ichorous off-
throwing  of cancers, is, owing no doubt to the fundamental cancerous
vitiation of the fibrin, remarkable for its  whitish coloration, its softer
glue-like consistency, its liquefaction  to a whitish, cream-like ichor.
   A point of great moment, in relation to the crasis, is the recognition
of an impress upon  general nutrition  indicative of  a predisposition to
tubercle, and consisting in certain developmental proportions  of textures
and organs; in a word, the  " tuberculous habit."   Another point of
equal interest is the relation of tubercle to other morbid processes, bound
up with primitive or consecutive anomalies of the crasis.
   There exists undeniably a habit, expressed in a  delicate construction
of the soft parts, in imperfect development of the muscular, with prepon-
derance of the vascular, system,  and especially in a so-called phthisical
build of the thorax,  commonly deemed ominous of pulmonary tubercle.
It is  essential,  however,  that  this build should not,  according to  the
vulgar notion, be imputed  to smallness of the lungs  within a seemingly
insufficient thorax, but rather to very voluminous lungs within a thorax,
the obvious narrowness of which, in  its antero-posterior diameter, is
amply compensated for by its length, with a relatively small abdominal
cavity, and small abdominal viscera.
   Nevertheless, tubercle does not always, nor exclusively,  thrive upon a
substructure like this.  The tuberculous crasis, like  the  local tuberculosis
of an organ, may become acquired in an individual of quite  a different
habit, as a consequence of surpassing external and  internal mischief.
   With reference to  the  second point, namely,  the  relation of  the
tubercle to other morbid processes, no  disease offers so  much that is in-
teresting,  that is corroborative  of views already set forth, that is practi-
cally serviceable and inductive of ulterior  research, as tubercle.   It is 
TUBERCLE.
237
especially distinguished by its exclusive relation towards several morbid
processes.
  The sum of an immense range of experience in point is to the follow-
ing effect:
  1. Cyst-formation, as a  new growth, is rarely found concurrent with
tubercle, either in the same organ or in the same organism generally.  In
this  sense  the proliferous cyst-formations  are distinguished.  Where
their seat is in the  abdominal cavity, as for instance in the  ovary, the
immunity against tubercle  is augmented by  an accessory circumstance,
in itself  most important, namely, the  coarctation of the  thoracic space
by pressure from beneath.
  Experience seems to show that it is more common for cyst-formations
to succeed to the extinction of tuberculosis, than the converse.
  A comparison of the occurrence of  both in  the various organs  esta-
blishes, as the extreme points of the scale, the well-known great frequency
of tubercle against the extreme rarity of cyst-formation in the lungs,
and the reversed proportion of the two in the ovaries, and next to these
in the  salivary glands.  This  relation seems highly important in refer-
ence to the affinity which cyst-formation bears to sarcoma and carcinoma.
   2. A similar antagonism, as shown from still more numerous observa-
tions,  prevails  between   tubercle  and  carcinoma.   Whenever   their
general correlation is susceptible of proof, cancer  has seemed  to succeed
to tuberculosis, tubercle rarely to become developed after the extinction
of cancer and its crasis.  Moreover, it must be repeated that to cancer,
and in particular to inflamed and ulcerating cancer, there is  sometimes
superadded, more especially in the lungs, a tubercle, marked by a whitish
coloration, a softish glue-like consistence, and a tendency  to resolve
itself into a  whitish cream-like ichor.   It has  the import of  tuberculo-
croupous impairment of a carcinomato-dyscrasial fibrin.
   A corresponding result of  much interest is  afforded by a comparison
of the scale of frequency of cancer and tubercle, as well as  of several
special local relations of both.
   They are diametrically opposed to one another,  as thus:
FREQUENT.	BABE.
Lung tubercle. Ovarium cancer.	Lung cancer. Ovarium tubercle.
Salivary gland cancer. Stomach cancer.	Salivary gland tubercle, Stomach tubercle.
(Esophagus cancer. Rectum cancer.	(Esophagus tubercle. Rectum tubercle.
Ileum tubercle.	Ileum cancer.
&c.	&c.
  Again,  the special localities present many  differences of their own.
Thus, in the uterus, the vaginal portion and cervix become affected with
cancer,  whilst tubercle fastens upon the mucous membrane of  the body
of the  womb, and  generally  stops  short  at  the  internal orifice.  The
epididymis becomes primarily and essentially tuberculous; the testis, can- 
238
TUBERCLE.
cerous.   In the  lungs the  upper section is peculiarly obnoxious  to
tubercle, whilst cancer occurs  at every part of the  lung-parenchyma.
In fine, cancer and tubercle possess a different import in the most vari-
ous organs according as the  one or the other is primitive or secondary.
Thus, cancer of the liver is  not rarely a  primitive, tuberculosis of this
organ almost invariably a  secondary affection, if not a  mere  participa-
tion of general tuberculosis.
  3. Typhus and Tuberculosis.—Typhus  associates itself with tubercu-
losis only under the influence of very intense epidemics; in other words,
it very  seldom attacks tuberculous individuals.   On  the other hand, a
fibrino-croupous tubercle-crasis  developes  itself not unfrequently in the
sequel to  typhus, and  with it local inflammation with  fibrino-croupous
exudation of a tuberculous nature.   This occurs in the shape of inflam-
mations of  the lungs,  and also of such  follicles of  the ileum as have
escaped the typhous process.   This determines,  from the  softening  of
the tubercle around the typhous  loss  of substance, a combination of the
so-called typhous with the tuberculous intestinal ulcer.
  This tuberculosis in  the sequel to typhus is without doubt based upon
the not unfrequent conversion of the  typhous to the  fibrino-croupous
crasis.   The conversion takes place at different periods, but frequently
at a very  early stage of the retrogressive typhous  process.
  There is a similar relation of  tuberculosis to the acute exanthemata ;
especially to scarlatina and  measles.   The tuberculosis following them
is, for  the most part,  fibrino-croupous, and  dependent upon a similar
conversion of the exanthematous crasis.
  4. Intermittent Fever and  Tuberculosis.—-The experience of foreigners
places their incompatibility with  each other beyond any  doubt.
  5. Bronchocele and Tuberculosis.—Although within the  range of our
own observation a moderate  degree of sporadic  goitre  has not seemed
necessarily to possess an exclusive relation towards  tubercle, the obser-
vations  of foreigners  as to the  exclusive  relation of  endemic goitre to
tuberculosis merit, nevertheless, to be noticed here.   Apart from  the
affinity in the  structural relations of  the enlarged thyroid gland, goitre
presents, in the outpouring of colloid, important  points  of analogy with
cysts,  sarcomata,  and  cancers,  in which colloid often constitutes  an
essential ingredient.   It would seem that, in endemic  goitre, it is  not
the mechanical hinderance to respiration  that occasions consecutively,
but an anomaly of the  crasis connected with  the  secretion of colloid in
the thyroid gland, that determines primitively the exclusion of tuber-
culosis.    (See Colloid.)   This is betokened  by  the  alienation of  the
general habit contracted with goitre, and  still more by  the fact that, in
districts where goitre is endemic, tuberculosis does  not occur, even in
individuals unaffected with the prevailing deformity.
  6. Rickets  and  Tuberculosis  do not readily combine.  Nay, rachitic
deformity and coarctation of the thorax  are scarcely ever found com-
plicated  with  tuberculosis.   It is, as yet,  undecided  whether, or  what
degree of, exclusiveness towards tubercle  absolutely belongs to rickets;     (
and, again, whether the latter  owe  not its immunity to a consecutive
disproportion of its own creation, namely, the deformity—the narrowing
—of the thorax. 
TUBERCLE.
239
  7.  Even the  arterial  disease upon  which  spontaneous aneurism
depends, and  which consists  in  the  endogenous  exudation  and strati-
fication of  a fibrinous substance upon the  internal bloodvessel membrane
(see  Abnormal Conditions of the Arteries) is, in its more highly deve-
loped grades,  very rarely associated  with tuberculosis.   The immunity
is, perhaps, based upon an exhaustion of the materials for tubercle, due
to the deposition of a solidifying blastema out  of arterial blood.  A
more decided  immunity is brought  about by  aneurisms, or by a single
extensive aneurism, in  the proximity of  the heart, involving the endo-
genous coagulation of  great fibrinous masses,  and a consequent hydrae-
mia through defibrination of the  blood.
  8. The relation  to tubercle of venosity (that is, an habitual prepon-
derance  of venous blood in the  system)  and  of  cyanosis,  as  resulting
from mechanical hindrance at the centres of  the  organs of circulation
and of respiration, is of paramount interest and even  of great practical
importance.   The  remarkable exemption from tubercle  brought about
by these conditions induces us to set forth the relevant facts, as nearly
as may be, in  their natural order.  They determine the  venous consti-
tution  in various ways, generally conforming in this, that they prevent
the arterializing of a sufficiency of blood;  whilst they  engender cyanosis
by hindering  the return of blood to the right chambers of the heart,
the said blood being arrested in the veins, and  consequently in the capil-
laries generally.   The relevant facts, ranged in a twofold series, accord-
ing as the  venous habit and cyanosis are dependent  upon the heart or
the lungs,  are as follows:
  (a.)  The first  place is due to the fact,  confirmed by daily experience
and  convenient  as a  starting-point for the  ensuing  considerations;
namely,  that  persons laboring  under  enlargement (dilatation,  hyper-
trophy, and their complications) of the heart, whether  primary or super-
induced  by mechanical obstruction at its  orifices, do not contract tuber-
culosis.
  (b.)  Nor does  tuberculosis co-exist with  such congenital vices of
formation in the heart  or the great arterial  trunks  [absence,  insuffi-
ciency,  coarctation of  either, persistence of  ductus arteriosus,  &c]
which, with their complications, result in  venosity and cyanosis, and, as
the anatomical measure of their significance,  in  augmented volume of
the heart.
  (c.)  Next in the series we have to mention the  immunity afforded by
many acquired anomalies of arterial  trunks, which resemble congenital
vices of  formation, such as coarctation from  compression, obstruction,
obliteration, or again by large aneurisms in the  vicinity of the heart.
Apart  from what has already been said  on this point, the  immunity is
due to  the mechanical impediment which the overpowering blood-column
in the dilated  aortal trunk opposes directly to the emptying of the left
ventricle, and indirectly to the  influx  of venous blood  into the right
heart.
  The same  immunity is  attained in  venosity and cyanosis  owing to
hindrance  to  the pulmonary  circulation; more  especially  where  the
impediment reveals its  serious character by  a dilatation of the right
heart. 
240
TUBERCLE.
  We may here further adduce :
  (d.)  The observation that the increased density of the lungs produced
by coarctation of the thoracic spaces, in higher grades of lateral curva-
ture of the spine, or in the rickety chicken-breast, excludes tuberculosis.
Nay! it is an important fact that, with the establishment of a deformity
of the spine in the shape of gibbosity, even  when  owing to tuberculous
caries of the vertebrae, the  tubercle-crasis is forever rooted out in con-
sequence of the narrowing of the thoracic spaces.
  (e.) The fact that the  compression  exercised by pleural  effusion, and
a consecutive,  abiding increase  of  compactness of the  one lung, as
denoted by a sinking in of the thorax, in like  manner extinguishes the
tendency to tuberculosis.   This effect is the  more  surely produced, the
greater the mechanical  obstruction,  and the consequent  disproportion
between the blood-mass and the lung-capillaries pervious to it;  and the
less  competent the other (vicariating) lung is to carry on the function of
arterialization.
  (/.)  The  fact that pregnancy arrests the progress of an established
tuberculosis; or, as we would correct and extend  this proposition, the
fact  that advanced pregnancy not only arrests a tuberculosis  already in
being, but also  obviates  the formation of tuberculosis  generally.  It is
the  effect of that  embarrassment of  the  thoracic  spaces, and  of that
resulting  condensation of the lung-parenchyma occasioned by  upward
pressure from the  abdomen; in other words, it is based upon a venosity
brought about by mechanical means.   It is probably for similar reasons
that the placenta very rarely,—the foetus perhaps never, becomes tuber-
culous.
  This  relation derives  further  interest from the rapidity with which,
after child-birth, that is,  after removal of the conditions which prevailed
during advanced  pregnancy, fibrin-erases  with their  respective exuda-
tory processes,  and amongst them  the  tubercle-crasis  and  tubercle-
deposits, take place, more particularly through  the medium  of inflam-
matory stasis.
  (g.)  To the same class is to be referred  the immunity from  tubercle
arising from every enlargement of the abdominal space, and the conse-
quent  narrowing  of the  thoracic cavity.   The exemption allotted to
patients  afflicted with vast ovarian cystoids  probably partakes of this
nature.
  (h.)  Again, the  fact that even congenital  smallness of the  pleural
sacs, paired with  primitive  smallness pf the lungs, and, as it mostly is,
with an inverse ratio of the  development of the abdomen and its viscera,
serves as a protection against tuberculosis.
  (i.) That in the earliest childhood (with closed foetal passages), owing
to a condensed state  of the lungs caused by predominant abdomen,
tuberculosis occurs, if  at all, very rarely.
  (k.)  The  exemption apportioned to those who  labor  under  chronic
catarrh, under vesicular  emphysema  of the lungs, or under bronchial
dilatation, was recognized even by Laennec.   The empirical recognition
of this  relation has even led to attempts to cure tuberculosis by the
forcible production of those conditions.   The real preservative  point
was, however, overlooked, both here and in another mode of cure aimed 
TUBERCLE.
241
at by others, namely, that of closing cavities in the lungs by forcible
compression of the thorax.  The protective and curative impulse con-
sists, even here, in venosity.  And this venosity is a consequence of the
destroyed  function, the  collapse and eventual  wasting  of  numerous
pulmonary lobules, through obstruction  of their bronchia with muco-
purulent  secretion;  in bronchial dilatation, through the concomitant
obliteration of considerable portions of the lung; in emphysema, through
lost  contractility  of  the  pulmonary, texture for  expiration, and conse-
quently embarrassed respiration, more especially, however, through the
destruction of extensive ranges  of the lung-capillaries.
   (I.) It will be readily understood  that  the dropsical crasis,  especially
when resulting from venosity, excludes tubercle.
   It will now become necessary to inquire how certain exceptional cases
are to be  explained.  Individual cases of the kind are represented in tu-
bercle associated with cancer, or with venosity mechanically brought about.
   (1.) The conditions mentioned as  excluding tubercle, operate thus only
in so far as the latter is based upon a hyperinotic crasis—an excess of
fibrin.  This does not,  however, prevent the small fund of  fibrin accom-
panying those conditions  from being, under  favorable circumstances, ex-
pended upon tubercle formation, which then becomes localized in a pro-
cess of exudation.
   (2.) The tubercle may  be the product of a local inflammation, in which
the  fibrin becomes tuberculous.
   (3.) The entire mass of fibrin may suffer a morbid change,  effecting,
as  intercurrent disease, a consecutive tubercle  crasis, which  becoming
exhausted by a corresponding exudation,  again gives way to the original
crasis.
   It is  thus that genuine  tubercle, when concurrent with cancer, may be
interpreted;  and this the more readily, that true hyperinoses  and fibri-
nous exudates not unfrequently  do  co-exist with cancer.   The tubercle
may be merely local, and the cancer no  less so.  It may,  however, be
local, and yet the cancer  be a general disease.  Or, again,  it may be the
product of an intercurrent primitive tubercle-crasis,  or of a consecutive
one  derived from a local process, and co-ordinate with those hyperinoses
and  Abrin-exudations which not rarely  supervene  upon inflamed  and
ulcerated  cancer, reflecting a secondary crasis.
   (4.)  As to the exemption afforded by venosity, there is  no doubt that,
to render  it complete, a high degree of the latter is requisite.   Since,
however, we possess no scale whereby to ascertain directly the grade of
a  protective  crasis, and to illustrate  the exceptions, we must  inquire
whether it be not  possible to  arrive  indirectly  and  approximatively at
this  recognition.  In the absence  of such  a scale, certain anatomical
changes must serve as the measure, so to  speak, of the anomaly.  They
consist in the degree of heart affection (dilatation) present, this furnishing
an available criterion for the amount of the  impediment to the circula-
tion, and therefore for the grade of the  venosity.   This  approximative
index with the aforesaid inferences, will  be  especially applicable where
the precise extent of  the  impediment is not to be immediately summed
up from anatomical data,  as in lung  affections, like catarrh and bronchial
dilatation, emphysema,  and preternatural density of the lungs.
  VOL. i.                          16 
242
TUBERCLE.
  We  attach importance to this relation of tubercle to the venosity
resulting from mechanical  impediments  in  the heart and lungs,—as
affording not alone  proof of the fibrin-crasis being the foundation of
tubercle, but also valuable indications for  medical treatment.
  We  have now to  consider the relative occurrence of tubercle in the
different organs and textures, and its peculiar processes of repair.
  It will be expedient, however,  as a preliminary point, to  determine
what is signified by scrofula,—what is the distinction—if there be any
—between  scrofulous and tuberculous substance.
  For  our  own part we hold tubercle and scrofula to be identical—tuber-
culosis and scrophulosis to be one and the same disease;  and  this upon
the following grounds, namely :
  (a.)  One and the same elementary composition, both anatomical, and,
so far as investigation has gone, chemical also.  This applies with especial
force to scrofulous substance, as compared with yellow tubercle.
  (b.)  Both are subject to the  same metamorphoses, namely, softening
and cretefaction.
  (c.)  The  tuberculous and the scrofulous ulcer are identical both in  the
same,  and  in different organs; for example,  the scrofulous skin- and
the tuberculous  intestine-ulcer.  The  same  identity  attaches to their
cicatrix.
  (d.)  Both frequently  coexist in the same  organ, sometimes without,
sometimes with, the appearances of inflammation.
  The  truth is, that the yellow tubercle is commonly called "scrofulous
substance," more especially  when it occurs in largish masses, and affects
in the  usual way the glands—the  lymphatic glands—in children.  Thus
the same substance concurrently  affecting the lungs and the bronchial
glands  is denominated, in the one instance tubercle, in the other scrofula.
  A scale  of the frequency  of  tubercle in the  various textures and
organs, offers but limited points of interest. According  to our experience
it would present in adults something like the  following series,  namely:
  Lungs.
  Intestinal canal.
  Lymphatic glands,  more particularly the abdominal and bronchial.
  Larynx.
  Serous membranes, especially the peritoneal and /pleural.
  Pia  mater.
  Brain.
  Spleen.
  Kidneys.
  Liver.
  Bones and periosteum.
  Uterus and tubes.
  Testicles, with prostate gland and seminal vesicles.
  Spinal cord.
  Striated muscles.
  For  children  this  scale  does not answer  completely.   In them  the
lymphatic  glands, together with the spleen, would take the lead, followed
by  the lungs with the bronchial mucous membrane, the brain, the serous
membranes, &c.
* 
TUBERCLE.
243
  The ensuing remarks appear to  us  well  deserving  of attention, as
affording  evidence  of the  imperfection  of any  summary scale  of fre-
quency.
  (1.)  At every point where capillaries  occur,  there may  be tubercle.
Epidermid formations and cartilage are  therefore alone exempt  from
tuberculosis.
  There are, however, vascularized organs in which tubercle very rarely,
if ever, occurs;  such are the  salivary glands, the  ovaries,  the internal
bloodvessel-membrane, the oesophagus, the vagina.
  Even vascularized new growths  may become the  seat of tubercle.
  (2.) If, which is  most important, we consider tuberculosis individually,
according to their primitive or to their secondary appearance, an entirely
different scale is set up.   The lungs and lymphatic glands, it is  true,
retain their uppermost rank, but are immediately  followed by tubercu-
loses, which stand very low in the foregoing scale, namely, of the urinary
system, of the female sexual mucous  membrane,  of the bones, of the
testicles with the prostate  gland and the seminal  vesicles.   Meanwhile
tuberculoses of the intestine,  of the larynx  and trachea, of  the  serous
membranes, of the  spleen and liver, take a very  subordinate position  in
the new scale, seeing that  they seldom, if ever, become the  primary seat
of  tubercle.
   (3.)  Accordingly,  certain tuberculoses which  in the first  scale occupy
 a high place, possess but a very subordinate  nosological  import.   They
 are seldom, if ever, primitive, but almost always secondary, dependent
 upon other tuberculoses often, indeed, only participant in general tuber-
 culoses.  The liver, spleen, kidneys, nay, in  many cases the lymphatic
 glands, stand in this relation to tubercle.
   (4.)  Tuberculosis almost invariably attacks several determinate organs
 concurrently, at the outset or at a very early period.  Of this  commu-
nion  we have examples, not only in the  joint tuberculosis  of lymphatic
 glands and of the implicated  organs, but also in that of the brain and of
 the lymphatic glands; of  the testis, prostate gland, seminal vesicles, and
 of  the urinary organs; of the spleen and  supra-renal gland, and of the
 lymphatic glands;  of uterine  and tubal, and of peritoneal; of pulmonary,
 and of intestinal, or of laryngeal tubercle.
   (5.)  Secondary tuberculoses have a sort  of groundwork or starting-
 point in certain pre-existing  tuberculoses.  In other  words,  secondary
 tuberculoses accede to already  existing  ones  according to  a tolerably
 constant rule.  Thus, tuberculosis of the lungs  or  lymphatic glands
 offers for all such secondary tuberculoses, a general  point  de depart,
 whilst, on the other hand, it  commonly  associates itself to  most  other
 tuberculoses.  Tuberculosis of the serous membranes  accompanies that
 of the implicated parenchymata; tuberculosis of the urinary system, that
 of the genital apparatus in the male.  (See "Tuberculosis," vol. iv.)
    (6.)  Again, the  mode of production of tubercle varies in the different
 organs.  Thus, upon serous membranes and in bone, tubercle  is, for the
 most  part,—upon  mucous membranes, very frequently,—in lymphatic
 glands and in the brain, not unfrequently the product of inflammation.
    (7.)  In fine, it is worthy of note that in every organ tubercle, unless
 thrown out with much violence,  has its  almost  invariable, and readily 
244                         TUBERCLE.
 demonstrable point of incipiency.   In the lungs it is  at  the apex, the
 upper third of the superior lobes ;  in the pia mater, at the  part investing
 the  base of the brain within the  common groove, running from the
 chiasma to the pons Varolii and the medulla oblongata or about the fossae
 sylvii; in the brain itself, in and about the gray substance;  in bones, in
 the spongy bones or parts of bones; in intestinal mucous membranes, in
 that of the inferior ileum; in the laryngeal mucous membrane, at the por-
 tion covering the  transversus glottidis muscle; in the testicle, in the
 epididymis; in the  female sexual apparatus, in the mucous membrane of
 the tubes and uterine fundus—that the deposition of tubercle first com-
 mences and concentrates itself.
   (8.) Again, there are a few marked limitations set  to the  advance of
 spreading tubercle.   For example,  tubercle of the larynx  never extends
 to the pharynx ; uterine tubercle hardly ever passes beyond the internal
 orifice, so that the cervix uteri and the vagina remain exempt.
   Tuberculosis very commonly proves fatal, if locally, by impeded func-
 tion, by palsy of the affected organ, in consequence either of the exten-
 sive, acute deposition of tubercle into its texture, or else of the ulcerous
 destruction of the latter in the process of so-called tuberculous phthisis.
 Or the tuberculosis may, as  a general disease, destroy life through im-
 poverishment  of the blood, through hydraemia or  the  serous crasis, an
 issue vastly favored where the tubercle is copiously and at  the same time
 rapidly thrown out, and where local tuberculosis  in important organs
 hinders the reproduction of blood.
   The cure of tubercle may take place in various ways.  Each of the
metamorphoses of tubercle may become invested with the character  of a
healing process.   Still, neither the decadence of tubercle, nor its ejec-
 tion  through the medium of ulceration, as local healing processes, are
 fraught with  any value for  the individual, unless  accompanied by the
 extinction of the fundamental, tubercle-producing crasis.
   The cure of tuberculosis as a general disease—as tubercle-dyscrasis—
 takes place now  and then obviously through the intervention of some  of
the processes and conditions already adverted to as excluding tubercle;
 at other times, through influences entirely occult.
   A question  connected with the local healing process of  tubercle here
 suggests itself, namely, as to  the  absorption of  crude tubercle ?   The
resorption of tubercle as formerly believed in, was probably  first repu-
 diated by Laennec, and  after him by  most pathologists ;  and although
valid grounds  can hardly be alleged for its impossibility, neither has  it
 ever been proved by direct evidence, nor is it  at  all within the compass
 of likelihood.
   The obsolescence, the cornification of gray tubercle, represents incon-
 testably its readiest process of involution.   As a direct  extinction of the
 tubercle, it would afford the completest cure, did it not concern a growth
 which  would fail to become destructive if it abided in its primitive crude
 condition.
   Of the two other metamorphoses affecting  yellow  tubercle, cretefac-
tion of what has undergone  softening  unquestionably presents the most
desirable process of repair, as will  become evident from  the following 
TUBERCLE.
245
remarks concerning the  other  metamorphosis, considered as a  healing
process, or as the basis of one.
  The softening of tubercle cannot of itself serve for a reparatory pro-
cess.   The elimination of softened tubercle through the instrumentality
of ulceration in its  vicinity, can alone pags current for such.
  But, taking into  account—
  (a.)  That it can only be brought about by ulcerous destruction of the
textures.
  (b.)  That, although the aim of this ulcerous process be to heal, it may,
when the  tubercles are numerous, readily induce exhaustion.
  (c.)  That the attendant inflammation—the  general disease being un-
extinguished—of itself determines tuberculous products,  thus extending,
without limit, the ulcerous consumption of the textures.
  (d.) That even under favorable crasial conditions, an infection of the
blood is possible  in tuberculous ulcers (cavities).
  Taking, we say, all these circumstances into  account, this curative
process must be  regarded as widely subordinate to that of cretefaction,
to which it stands in nearly the same relation as the removal from the
body of a foreign  substance by a debilitating ulceration, to the same
substance being rendered innocuous by incapsulation.
   The healing of a tuberculous ulcer or cavity,—of tuberculous ulcera-
tion,—can therefore only take place provided the accompanying inflam-
mation, owing to extinction of the  tuberculous crasis, ceases to deposit
fresh tuberculous matter, and determines organizable products  instead.
The loss  of substance is made up for by new-formed shrivelling scar-
texture.  Where the tubercle has not been completely eliminated in the
phthisical process,  the residue may become  isolated by a pap-like inspis-
sation and eventual cretefaction.

            Albuminous Tubercle.  Acute  Tuberculosis.

  Under  this denomination is understood  a disease  presenting many
points, both of resemblance and  of dissimilitude with  the tuberculoses
already discussed.  It devolves upon us  to investigate  these analogies
and differences ;  the former appearing to us to preponderate so far as to
preclude our separating the disease from tuberculoses generally.
  There is a disease which, under an acute course, and  under  typhoid
symptoms, determines a  tubercle differing  in  many respects from the
fibrinous.   It always  represents  solid,  mostly poppy-seed-, rarely,  if
ever, millet-seed-sized, sometimes limpid,  softish,  glutinous, gray granu-
lations, either of vesicle-like or of a dull transparency, often only cogni-
zable under a favorable incidence  of light;  at other times, although far
less frequently, opaque, whitish, or whitish-yellow.
  On a closer inspection, this tubercle appears marked by cell-formation.
It is found to contain—
  (a.) The ordinary nucleated, exudate cell, in considerable numbers.
  (b.)  Cells with two or three nuclei.
  (c.)  Cells with filial  cell-formation.
  (d.) A  structureless soft basement connecting these elements.
  It exudes always in great abundance under the symptoms of hyperae- 
246
TUBERCLE.
mia, in scattered granulations, uniformly distributed through the paren-
chyma of the affected organ, and either all at once, or at intervals rapidly
succeeding each other.  A manifest  equality of size and character  is(
observable in all  those  deposited simultaneously,  or  during the same
attack.   With it there is always effused a grayish, sero-albuminous semi-
gelatinous humor, with which the diseased textures  become infiltrated.
•   This  tuberculous  deposition  affects not only  entire organs or large
sections  of organs and of textures, but commonly several organs  and
textures simultaneously or in rapid succession;  a  single one, however,
generally operating  as the main point of concentration.   Its  seat is in
the lungs, the pia  mater, especially at the base of the brain, the spleen,
the serous membranes, especially the peritoneum.
   This  tuberculosis is only in rare  instances the primitive one.   For
the most part, it is based, so to speak, upon a precursory fibrin tubercu-
losis of  the lungs or lymphatic glands.   In these cases its point of con-
centration  is  generally  either  the organ  previously  affected, or some
structure standing in immediate relation with it.
   The disease proves fatal through palsy of  affected organs essential to
life, or else through  dyscrasial influence.
   This tubercle is subject to no metamorphosis.
   The dyscrasial character of the blood is manifest, and closely assimi-
lates  to  the  exanthematous crasis.   (See " Crases.")  In accordance
with it are the livid coloration of the common integument  in the dead
subject, the dark  coloration of the muscles,  the  general appearance of
flabbiness, the serous infiltration of the parenchymata.
   In  this description of  the disease  we recognize the albuminous crasis,
and a product  which, in its subordinate  coagulability,  its soft, gluey
character, its cell-development, gives evidence of its albuminous nature.
   This tubercle renders  it probable that albumen, without previous con-
version  to Abrin, may acquire a  considerable amount of coagulability,
and become  tuberculous;  nay,  that where  the opaque yellowish or
whitish-yellow  acute tubercle does not form  upon  a basis  of  croupous
Abrin, even albumen may, without  conversion into fibrin, acquire  the
croupous character.
   In this description we  recognize not only the distinctions, but also the
analogies between the Abrinous  and the  albuminous tubercle.  These
analogies stand forward  the more prominently if we recall to mind the
fibrin tubercle of acute production.
   Such analogies, apart  from the resemblance in  outward form of the
two heterologous  deposits, that is, the tubercle  form; apart from the
uniform size of the granulations thrown out at the same period of exu-
dation ;  and apart from  their equable dissemination through the paren-
chymata ; are as follows:
   (a.) Both are rarely the primitive tuberculoses in an organism.
   (b.) Both are thrown out under manifestations  of hyperemia.
   (c.) With both there is effused, as a sort of vehicle for  the coagulable
portion  of the entire exudation, a serous, sero-albuminous fluid.
   (d.) Both affect the same organs and sections of organs.
   (e.) The albuminous  tubercle  bears the same relation towards other
diseases as the Abrinous. 
              ALBUMINOUS  CRUDE  BLASTEMATA.          247

  (/.) In by no means rare instances, a step-like transition from  the
Abrinous to the albuminous tubercle is incontestable.  Upon the ground-
work  of  a Abrin-tuberculosis, which has undergone frequent phases of
phthisis, there exudes, wTith augmented  dyscrasis, in  the lungs more
particularly,  a tubercle which, with every fresh act of exudation occur-
ring in rapid succession,  becomes  softer and poorer in Abrin, until ulti-
mately  reduced to a soft, semi-fluid, albuminous  tubercle,—a consum-
mated acute tuberculosis.
  (g.) Occasionally we discover, especially in the texture of the pia mater
at the base of the  brain, an exudate  consisting of albuminous tubercle
and tuberculizing  croupous Abrin, a  primitive combination  of the  two
products.
  (h.) Not only does albumen enter into the composition of Abrin tuber-
cle, but a certain amount of Abrin modiAes that of the  albuminous
tubercle.  A complete exclusion of the one or the other is hardly con-
ceivable, and it is  only the predominance of the one or of the other that
characterizes the product.  Between the extremes of  Abrinous  and of
albuminous tubercle there exist numerous middle and transition forms.


                   ALBUMINOUS CRUDE BLASTEMATA.

   Under this head we shall discuss certain products in their  nature pro-
bably albuminous,  and essentially distinguished from other  albuminous
blastemata by  their persistence in the condition of crudity.   Owing to
this persistence, as also to their being founded in  a dyscrasial element,
we rank them along with tubercle, with which, moreover, they occur not
unfrequently in consecutive alliance.
   They are,  for the most part, solidiAed blastemata, resembling  to  the
naked eye a  translucent  coagulated albumen.   Now and then, however,
they  are opaque,  and of a  turbid  whiteness.    They  consist  of an
amorphous, glebous, transparent basement, and of nucleus formations.
   They occur in certain parenchymata in the shape of inAltration—very
rarely in that of a collection of roundish nodules from the size of a hemp-
seed to that of a pea.  The liver,  the spleen,  and  the kidneys are known
to become affected with these inAltrations, which give to the surface of
the organ  a brawn-like aspect with a transparent margin, frequently
representing  a spurious hypertrophy of the organs  named.  (See " Hy-
pertrophy.")   Whether these blastemata occur in one, or in several, or
in  all of those organs, they mostly  occasion considerable enlargement
thereof, and  at the same time a notable change in their consistency, the
parenchyma  becoming compact and of doughy brittleness.
   The out-throwing of these blastemata occurs in  an insensible manner.
   In  point of fact, they  comprise  that partly more or less  solidifying,
whitish, partly viscidly  fluid  blastema  effused into the parenchyma
of the kidney in Bright's disease, particularly in  certain  of  its chronic
forms.
  As may be inferred from the above, and as experience amply conflrms,
these blastemata never  occur  but in connection  with high grades of
general  dyscrasial disease; such, for example,  as rhachitis, mercurial 
248
UNORGANIZED  NEW  GROWTHS.
cachexia, inveterate syphilis, ague-cachexia, and especially certain tuber-
culoses.
  The deposition  of these blastemata is, therefore, never a local affec-
tion, but invariably indicative of an anomaly of general nutrition.  It is
clearly  dependent upon dyscrasis, which may consist in an  excess  of
albumen in the blood, and  be either primitive or secondary, as in the
tuberculosis resulting from the exhaustion of Abrin.   The consequence
of a copious and extensive secretion of these blastemata  is the eventual
exhaustion of albumen, and a watery condition of the blood [hydraemia],
inductive of dropsy, anaemia, &c.
  These blastemata usually abide altogether, and throughout in their
primitive  condition.   Occasionally,  however,  there  is  observable,  at
certain spots, a transformation of their mass  into molecular  fat.  They
become  opaque; of a whitish dulness; friable.   This is especially the
case in the liver and kidneys, and  it is not improbable that cera-larda-
ceous infiltration of the liver  is the result of a progressive, diffused con-
version of this albuminous blastema.
                 II. UNORGANIZED  NEW GROWTHS.

          A.—OF UNORGANIZED NEW  GROWTHS IN GENERAL.

  These lack both the internal order and the deAnite forms  which cha-
racterize organized new growths, and  their development comes under the
dominion  of chemical laws.   Between the rudiments of what  is, and
what is not  organized, there  is no  distinction  in  point of form.   In a
chemical sense non-organized growths are composed both of unorganized
and of organized substances, either  singly or conjointly, and  it is even
common enough for a new growth to be made up through the mechanical
blending or  interlacing of organized  with unorganized materials.  All
these considerations taken together preclude any marked  discrimination
between the two.
  There are, upon the one side, undoubtedly new growths representing
perfect unorganized formations, for example, certain  concrements.  On
the other side, however, non-organized new growths originate under con-
ditions and  forms  which have induced us, notwithstanding  their unor-
ganized nature, to discuss them along with the organized  new growths.
We may instance the forth issuing  of lime-salts—as cretefaction, ossifl-
cation, incrustation;  of the free fats ; of colloid;  of tubercle.
  The material for non-organized new growths in general, is contained
both in the textures, and in fluid and  solid blastemata;  the material for
a special order of non-organized new growths, in the  proper fluids of
secretion.  Its nature varies  considerably.  It consists of protein sub-
stances, certain gluten-substances, horn-substance, fats, pigments, acids,
salts.    In  a more extended  sense,  even the  various  gases  and fluids
occurring in textures, or in the cavities of the body or of organs, the
fluid of genuine dropsy for instance, belong to the class.
  Without for the present taking these last into the account, we have to
observe with reference to unorganized new growths: 
UNORGANIZED  NEW  GROWTHS.
249
   The elementary forms are  the amorphous, the glebous,  the laminate,
 the granular (down to the Anest molecule or point-mass), the crystalline.
 Certain  substances possess a  determinate  form,  dependent, however,
 for the most part, upon their peculiarity of  composition, upon the  con-
 ditions under which they become severed from their  primitive combina-
 tions, and upon their mode of  development.  Thus  protein  substances
 occur, both structureless, and in a glebous or a molecular form.
   These materials constitute secondary formations, either alone or  with
 the intervention of a bond-medium, for example, mucus.  This is  often
 furnished, together with the external moulding or form of the new growth,
 by the glutinous basis of a texture;  for example, in the so-termed ossifi-
 cation of a Abrous tumor.   Both in form and size they manifest  great
 variety, not readily susceptible, however, of generalization.   We allude
 more particularly to calculous concretions !   In consistency  they are  in
 various degrees soft or  firm.
   Above all, their chemical composition varies  greatly.  As regards
 concretions and calculi, these readily divide into two groups, namely, into
 such as form  out of fluids of secretion, and consist of the respective com-
 ponents  of those fluids, and into such as become developed out of blaste-
 mata and textures.   These last have a composition  corresponding  with
 their base, and very commonly  consisting of phosphate and carbonate of
 lime, and of magnesia.
   Respecting the origin—the mode of production—of non-organized new
 growths, it may be stated generally—
   1. They are  exudates  or secretions in  a primitive form  of  non-
 organization,  as exemplified in crude fibrin, and encysted colloid and  fats.
   2. They are the result of various transformations of such products.
 To this order belong:
   (a.) Formations arising out of the conversion of exuded and  secreted
 protein materials into  glutinous, into horny  substance, into fat; for ex-
 ample, the conversion of fibrin and albumen to colloid, to horny substance,
 to fat in the molecular  or crystalline form.
   (b.) Formations arising out of a process imitating ossification in fluid
 or solidified,  unorganized or  textural bases; a liberation of lime-salts
 (phosphate and carbonate) out of their primitive combinations, as crete-
 faction, ossification, lime-incrustation, concretion.   (See "Bone Forma-
 tion.")
   (c.) Formations brought  about by a  more palpable deposition of all,
 or only of certain, components of a fluid in which they are held in solu-
 tion  or suspension.   They are most  especially prone  to form in secreted
 fluids, and either consist purely of specific  ingredients  proper to them,
 or occur blended with other elements.   They constitute calculous concre-
 tions.  The cause of their separation is manifold.  It may be that the
 fluid has  become more concentrated, for example,  by  loss of water, their
 solvent medium, through  exosmosis (resorption)  or more^ especially by
 evaporation.   Again, we may mention, besides the  precipitation _ from
fluids of  certain specific components, the inspissation and exsiccation of
secreted and  exuded  fluids in their totality; for instance, of mucus, of
ear-wax,  of the smegma praeputii, of the  bile, of exudate,  of pus, &c.
Or else it is a consequence of a  chemical conversion of the fluid,—of the 
250
UNORGANIZED  NEW  GROWTHS.
solvent, or of the dissolved substance.   For  instance, the  free acid of
normal urine retains the phosphatic earths in solution; when, however,
the urine is rendered alkaline, be it by the presence  of  mucus or exu-
date, or by conversion of the urea into carbonate of ammonia, the phos-
phatic earths become precipitated.   If  the lithates present in the urine
become decomposed by an excess of acid in the urine,  the lithic acid, as
the less soluble, is thrown  down.  The soluble phosphate of magnesia
present in almost all the fluids becomes  precipitated, the moment that it
enters into a combination with ammonia, to ammonio-phosphate of mag-
nesia.
  Unorganized new growths  possess  sometimes  a local, sometimes a
general import.   Thus,  urinary calculi may be the result either of mere
local contingencies, or of various anomalies of general nutrition, that is,
of a dyscrasial process.

         B.—OF UNORGANIZED NEW GROWTHS IN PARTICULAR.

  We have here,  in the first place, to bring forward and to examine in
detail the substances which constitute new growths.
  1. Protein substances.—The primitive form in which these emerge
from their solutions, is that of a structureless or glebous mass, in various
degrees of coagulation,  and that of an elementary granule  down to a
pulverulent point-mass.  The reason for their appearance in these forms,
that is, the reason for the general coagulability, and a fortiori for their
specialities of form and coagulation, is quite obscure.   That which spon-
taneously undergoes rapid and firm coagulation passes current for fibrin;
that which coagulates more slowly and less perfectly under  a manifest
progressive change in the medium of solution, for albumen.   The mole-
cular form appertains in particular to the higher  grades of oxidation of
the protein  substances  (croupous  and pyin-holding fibrin).   Since  the
influences which  produce the coagulation and precipitation of albumen
in experiments, do not presumably take place within the organism, the
discovery of the  modiflcations suffered  by albumen through the agency
of water, acetic acid, and the like, is highly deserving  of attention.
  The protein deposits are insoluble in ether and in mineral acids.  By
acetic  acids they are rendered  translucent,  and  ultimately dissolved.
By caustic potash and fuming hydrochloric acid they are slowly dissolved
—by the latter with a lilac tint.  An aqueous solution of iodine colors
them yellow.
  The glutinous  and horny substances emerging  out of the protein-sub-
stances are  amorphous,  or  have  a glebous or a  stratiform,  elementary
composition.   In their  physical  properties they approximate, more or
less, according  to their grade of perfection, to gluten  and to urea; in
their  chemical reaction,  to various modiAcations of gluten  (gluten,
chondrin, pyin, &c), and of urea.
  2. Fats.—Their elementary form of occurrence is that of drops, or of
an  amorphous solidiAcation ; of  granules ;  of  crystals.   Little is known
concerning the nature of fats originating  thus, more especially of those
assuming the form of granule (elementary granules, both  free and in-
celled, discrete and aggregate),  or developed out of blastemata and  tex- 
UNORGANIZED  NEW GROWTHS.
251
tures through  conversion of protein-substances, and probably even of
gluten.
  The fats cognizable by their form and chemical relations are :
  (a.) Elain.—It occurs in variously-sized drops, both free and incelled.
In this form it is usually set free out of emulsion-like compounds; in the
form of elaic acid, out of saponaceous compounds, or out of combinations
with other fats, for example, in exudates, in  medullary carcinoma.  It
frequently represents  an effusion of the contents of fat-cells, consequent
upon gangrenous or ulcerous destruction.   The drops  resist the action
of water and of acids, but dissolve on being  boiled with potash, and still
more readily in ether or heated alcohol.
   (b.) Margarin  and margaric   acid.—These  occur  in  microscopic
needle-cyrstals, for the most part  aggregated in stellate groups or bun-
dles.  In this shape the margarin emerges, after  the body has become
cooled, from its solution  in elain,  either within the fat-cells,  or without.
The crystals of margaric acid, soluble in concentrated,  heated alcohol,
are, according to Vogel, probably a product of decomposition, wrought
out  of the margarin of the fat, it  may be, by a free acid, so often deve-
loped in gangrene.
   (c.) Cholesterin.—When  cognizable  as  such,  it  occurs  in tabular
crystals, representing rhombic planes.  Many, however, of the aforesaid
fat-granules  are likewise cholesterin.  It almost always  occurs  along
with other fats, and often very copiously; for instance,  in gall-stones, in
the  atheroma of arteries, in encysted tumors.   The fact of cholesterin
so frequently occurring  in fluid and solidifled protein substances during
their disintegration,—as in  exudates, in  tubercle, in stratiform coagula
upon the inner coat of arteries, renders it probable that, like other fats,
it is the product of a decomposition of the elements of those substances.
This seems to us more probable than that it exists preformed in combi-
nations which cause it to be held in solution.  Its detection in the blood
does not appear to us a valid objection to this.  It is soluble neither in
water, nor in acids, nor  yet in alkaline solutions, but only in ether and
heated alcohol.
   (d.) Stearin.—Its occurrence is not proved  with certainty, although,
under certain  conditions, in which fat assimilates to  the  suet  of the
wether, not quite improbable.
   3. Pigments.
   (a.) Black,  brown, russet-yellow pigment (See "Pigment"), in the
shape of molecular granules; the last two occur, also, adherent to micro-
scopic crystals of ammonio-phosphate of magnesia.
   (b.) Bile-pigment, as  a Anely granular precipitate of a  yellow-brown
color, insoluble in water  and in most of the acids,—soluble in a boiling
potash-solution, with  a  greenish-brown  tint.   Nitric  acid  destroys it,
after causing it to pass through phases Arst of green, then of blue, and
lastly of red  coloration.
   4. Lithic acid and lithates.
   (a.) Lithic acid.—The  fundamental type of its crystals is the rhom-
boid prism, which, however, often  appears cut down to a rhombic plane.
The  crystals, frequently seen grouped into  rosettes  (Simon and Vogel), 
252
UNORGANIZED  NEW  GROWTHS.
are difficult of solution in water, insoluble in acids, alcohol, and  ether.
Potash causes their gradual solution.  They occur in the urine.
   (b.) Lithate of ammonia, as a flnely granular precipitate, colored of a
dingy yellow, yellow-red, russet, rose-tint; difficult  of solution in cold
water;  less so in hot.   The  effect of  acids is to isolate the lithic  acid,
which, under the microscope, is then seen to develope its crystals.
   5. Lime-salts.
   (a.) Basic phosphate of lime, as a  gelatino-granular mass, soluble in
acids.   It occurs both in fluids and in solidifled formations, in a soluble
combination of protein-substances, with gluten, out of which it separates
—especially in the shape of cretefaction and ossiAcation—in the form of
molecule.
   (b.) Carbonate of lime, in the shape of granular  deposition,—in the
cell-incrustation, of stratefaction—either alone or in union with the fore-
going substance.   Soluble in acids, with effervescence.
   (e.) Oxalate of lime,  in octohedral crystals,  sometimes remarkably
minute;  insoluble in water, alcohol,  ether, acetic acid; soluble in hydro-
chloric acid.   Found in the urine.
   6. Ammonio-phosphate of magnesia, in  crystals of various shapes.
When rapidly formed, they cluster together in stellate groups of needle-
shaped crystals, or represent denticulate, leaf-like forms.   When slowly
developed,  they constitute trilateral prisms, in which both angles corre-
sponding to  the same lateral-edge are truncated.    The crystals are
readily  soluble in  acids—even  in acetic acid.   The  occurrence of this
salt is extremely frequent.  Wherever a development of ammonia takes
place, the wide  dissemination of phosphate of magnesia determines the
formation of the insoluble triple phosphate.
   7. Sulphuret of iron, in molecular granules, soluble in acids and pre-
cipitable out of these by means of sulphuret of soda.
   Such are the  principal and  the better known substances which,  inde-
pendently  of, or in combination with,  others, compose the bulky un-
organized  formations, as so-called  concretions  or  concrements.   We
shall treat of these generally; dividing them into two great series, namely:
   1. Into  such as are essentially protein-substances ; or  into such as
consist of gluten or horn-like substance, of fat, and, lastly, of the phos-
phates and carbonates of lime and magnesia ;  it matters not whether the
latter be directly thrown out as such, or  whether they have, as usual,
become  obviously developed  out of the former,  that  is, out of the pro-
tein-substances.
   2. Into  such as  have comparatively a varied  composition, and are
marked by the speciflc substances which they contain.

                            FIRST SERIES.

   (a.)  Protein  concretions,  as coagulations  within  the bloodvessels__
vegetations ;  as  exudates in parenchymata, upon membranous surfaces *
as free bodies in serous cavities, tubercle, &c.
   (b.) Accumulations of gluten-like, colloid substance, commonly within
cyst-spaces;  and cornified protein concretions, for example, of the valve-
vegetations in the heart. 
UNORGANIZED  NEW GROWTHS.
253
  (c.)  Fat, as the  cyst-contents;  or as accumulations  within serous
cavities ;  in parenchymata, in the shape of spherical or irregular masses.
Frequently in combination with the following, namely :
  (d.)  Bone-earth concretion, so-called cretefaction and ossification, as
developed, not alone in the protein and gluten-holding unorganized base-
ments already adverted to, but also in fibroid and cartilaginous textures,
in a mode and form which, together with their relations  to the normal
ossification of bone-cartilage, we have discussed in  another part of this
volume.   [See " Bone Formation."]
  The concretions consisting of lithate of soda, found in the sheaths of
tendons, within  capsular  ligaments, even in  the spongy texture of the
articular terminations of bones, constitute an exception only as regards
the nature of the substance itself.
  The significance of concretions of this series differs with the organ
affected ; thus, concretions  on  the heart's valves are, perhaps, the most
important of all.

                            SECOND SERIES.

   To this series belong the concretions in and arising from fluids of
secretion.   We divide them into two species :
   (a.) They result from  the precipitation of  one or of several of the
specific components of a secretion, animal matter entering into their com-
position for the most part only in small quantity and by way of a bond
medium.
   They constitute the genuine stony concretions or calculi, which, when
diminutive, are termed gravel or sand.
   The  size of  calculi is,  as may be inferred from what was just stated,
extremely various, from  that of  a fine, just perceptible sand-grain, to
that of a concretion filling up the  largest secretory canals and reservoirs.
  In smaller, solitary concretions the form is mostly  the spherical;—in
larger ones, it corresponds  to that of the said  canals and  reservoirs, as
in the instance of renal calculi,  and is subject  to much  modification.
Where many concretions co-exist, they acquire from reciprocal pressure
and friction, the most varied,  polyedrical shapes,—as in the case of
urinary calculi, and especially of  gall-stones.   Their surface is  smooth,
polished, or else knobbed and uneven, stellate, thorny, rough.
  Their consistence mainly depends upon their chemical composition.
  They reside  at large in  their  respective cavities, or else, filling  the
latter, they lie  firmly impacted.   Or again,  they adhere as if  glued or
soldered at some point, through the medium of  fibrinous exudate.
  Their  structure varies extremely.   At their  nucleus they exhibit an
agglomeration  of an  amorpho-granular  precipitate.   Or  again, they
consist of concentrical strata of the same  character, or else of a crystal-
line  precipitate; or lastly, they are altogether of crystalline fabric, as
in the case of certain lithic acid calculi, but  particularly of cholesterin
concrements in the  gall-bladder.
  The first impulse  to their formation is sometimes given by foreign
bodies introduced from without, or by coagulate,—endogenous products.
The concretions represent,  in the first instance, incrustations of things 
254
PNEUMATOSES  AND DROPSY.
in various  degrees alien to their composition.   Thus, for  example, on
the one side, a great variety of foreign bodies which have  lapsed into
the urinary bladder, give rise to lithic acid calculi;  on the other side,
inspissated bile,  or  bile-pigment, to cholesterin  calculus in  the  gall-
bladder.
  To this category belong lithic acid calculi, salivary calculi, lachryma-
tory calculi, prostatic calculi, gall-stones, many intestinal concretions.
  (b.)  They are due to  the inspissation and desiccation [through exos-
mosis or  evaporation] of some fluid of secretion  either within or exter-
nally to its secreting canals and cavities.  Here the concrement consists
of the ingredients of the secretion in their totality, including, of  course,
a considerable amount  of so-called animal matter, and with  it of  or-
ganized elements.  Proportionately to the degree of  inspissation, the
concrement is soft; or,  it may be, of a stony hardness.  Concretions of
this  kind  very often become  developed in cyst-like dilatations  of the
follicles, in which the secretion  accumulates and  stagnates,  and  the in-
spissation of the  contents of  encysted tumors of new formation,  applies
here in its most extended sense.  The physical and chemical properties
are, it will be readily conceived, extremely inconstant and variable.
  This group comprises concretions in the follicles of  the skin,  in mu-
cous follicles,  in  the tonsils, in  the nasal and pharyngeal cavities, upon
the glans and prepuce, and  certain  intestinal  concrements, especially
those occurring in diverticula;  finally, the  inspissations of colloid,  and
of other cyst-contents.
                         CHAPTER X.

                    ANOMALIES OF CONTENTS.

  In this chapter we have to treat of:
  A. Pneumatoses and Dropsy, which we  have already adverted to as
non-organized new formations.
  b. Foreign substances introduced into the body.
  c. Parasites, that  is  animals, and  vegetable  growths, occurring in
and upon the^ living body.  We give them a place in this chapter be-
cause, according to the  researches of  modern  science  they are to be
numbered amongst the things that are received into the organism from
without.

                   a. PNEUMATOSES AND DROPSY.

  1. Pneumatoses,—the accumulation of various gases has been ob-
served as emphysema, both within textures,  and more particularly in
almost every cavity of the body and of its organs.   The scale  of  fre-
quency  varies, indeed, according to  the nature of the gas, and to its
mode  of origin.  There  are, however,  organs in which gas-accumula- 
PNEUMATOSES  AND  DROPSY.
255
tions of every kind are extremely common; and again, others in which
a development and accumulation of gas  are under  all circumstances
very rare.
  The modes in which gas-accumulations originate resolve themselves
generally, into the following :
  (a.)  The gas accumulated in the texture or  in the cavities of the body
or  of  organs,  is atmospheric  air which has penetrated from  without.
This applies to  most kinds of emphysema,  and of  gas-accumulations
in the pleural  sac, partly to those in the stomach, perhaps also to the
rare instances  of gaseous collections in  the uterus, and in the urinary
bladder; lastly,  to the presence of gas in the blood after the lesion of
veins, particularly those of the neck.  Most examples of interstitial emphy-
sema and of pneumothorax are the result of lesions of continuity, through
either  wounds or ulceration in the bronchial passages or in the lungs.
  By tarrying in preternatural localities, the atmospheric air suffers a
change similar to what it  undergoes in the lungs, its oxygen becoming
exchanged for  carbonic acid, with the superaddition of aqueous vapor.
  (b.)  The gases are products of decomposition.—To  this category are
to be reckoned, besides those gas-accumulations arising out of putrefac-
tion after death,
   a. Gas-development out of the blood-mass,  from putrid decomposition
of  the latter;  out of blood  perishing through  absolute stasis;  finally,
out of decaying normal textures  or  morbid products, for example,
sloughing cancers, or exudates undergoing decomposition.
   /?.  Gas-development in the stomach and intestines, the details of which
concern special anatomy.
   2. Dropsy, whereby we understand genuine serous  dropsy, that is, a
fluid mostly alkaline, in its purity colorless and limpid, and analogous in
the quality of its ingredients to,  although originally  thinner than, the
serum of the blood;  a fluid which, apart from the accidental admixture
of  exudates, pus-cells, blood-globules, epithelia and  the  like, contains
nothing  beyond unorganized effusions of albumen, pigments, fats (cho-
lesterin), and salts.   Under no conditions has it of itself alone the signi-
ficance of a blastema.
  It consists, chemically  speaking, of water, albumen,  fat and extractive
matter, and of salts,  the chloride of sodium preponderating over the rest,
namely, the carbonates and phosphates, of alkalies, and of alkaline earths.
Generally speaking, its proportion of water is greater  than that in blood-
serum.  The albumen is subject to the greatest fluctuation, down to an
infinitesimal allotment.
   This relation is liable to various and not unfrequent deviations.
  A red coloration is due to blood-pigment.
  A yellow, or yellowish-green coloration, to  bile-pigment.
  A whey-like turbidness, a milky-white appearance,  may  be owing to
certain of the admixtures adverted to, such as epithelium, but especially
fat, and to an albumen precipitated by an excess of water [relatively to
the saline contents].
  Sometimes the fluid has a faint acid reaction.
  A notable proportion of albumen  renders  the  fluid viscid, adhesive,
synovia-like. 
 256              PNEUMATOSES AND  DROPSY.

   This albumen, for the most part, shows itself to be  pure ; and  not to
 differ from that of blood-serum; or else it exists as albuminate of soda.
 It occurs, however, in certain other tolerably well-known, and without
 doubt in many other as yet unknown modifications.
   Occasionally the dropsical fluid contains urea.   The  accumulation of
 the fluid in the textures constitutes oedema, of which species  of infiltra-
 tion every organ may become the  seat.   Its collection in cavities  of the
 body, or of organs, constitutes  the dropsies.   Moreover, the serous effu-
 sion developed beneath the vesicated epidermis in  erysipelas, in  burns,
 and through  the agency  of cantharides, is  deserving of general mention
 here.
   The mode  of origin of dropsy varies:
   (a.)  The purest dropsy arises from retention of the  blood in the veins
 through mechanical hindrance to  the circulation.   Its  extension varies
 according to  the seat of the obstruction, being considerable in proportion
 as it affects the centres of the circulation.   It is in all probability  the
 veins, even the larger ones, which, in a  dilated and thin-walled condition,
 suffer an  out-throwing  of  dropsical fluid to take place from the blood.
 The exudation  will be considerable, proportionately  to the  amount of
 hydraemia—that is, of the serous crasis—that prevails.
   Dropsy is,  without doubt, determined by the lymphatics in a similar way.
   (b.)  Nor is there any  doubt  that  serous  effusion takes place, in like
 manner, from the capillary vessels.  This mode of  occurrence applies to
 the dropsy resulting from general debility;  to that  arising in  palsied
 parts;  to that referable to hydraemia.   Again, we  may attribute  to the
 same source that acute or chronic oedema consequent upon mechanical
 capillary hyperaemia, both active and passive; and, lastly, that  oedema
 founded in a  slight degree of stasis, or  attendant upon  consummate in-
 flammation.   Of the  latter description are  those outpourings   of  the
 blood-serum precursory to the genuine exudation of plasma in the inflam-
 matory process;  the oedema encircling  areae of inflammation;  the
 aforesaid  serous  collections beneath  the  epidermis,  in erysipelas,  in
 burns,  &c.
   (c.)  In fine, dropsical effusions  are brought about by attenuation of
 the blood,—or the serous crasis, a condition frequently combined with
 the aforesaid causal influences.
   The  consequences  of serous  effusion vary greatly according  to  the
 nature of the organs or textures concerned, to the extent of the accumu-
 lations, to the acute or chronic form of their  occurrence, and to their
 duration.   The relation of the textures generally  is  of much interest.
 In acute dropsy the textures are in various degrees congested, reddened,
 and withal—more especially the lung texture—lax, easily torn;—very
 delicate textures, for example, that of the brain, softened and destroyed.
 In chronic, enduring dropsy, on the contrary, they are discolored,  pallid,
 bloated with  imbibed serum. Smooth membranes become turbid and dull,
 the contractile fibre paralyzed.
   Dropsical fluid is either wholly or partially re-absorbed, or continues
 unchanged.   In  the  second case, the watery part  being  first  of all
 absorbed, it  becomes concentrated to an  albumen,  a synovia, or  a thin
jelly-like mass. 
PARASITES.
257
   In what manner the various oedemata and dropsies may become peri-
lous, and eventually prove fatal, is sufficiently evident.

                         b. FOREIGN  BODIES.

   Inanimate  foreign bodies  are  not unfrequently met with  in the
organism.
   They  are introduced  accidentally  or  designedly, either through the
natural orifices, as the mouth, the anus, the orifices of the urethra and
vagina, the ears, the nostrils;  or else  by violence, at various parts, as
by means of projectiles, of puncture, of a blow, of cautery, &c.
   They include things the most dissimilar, as Ash- and other bones, fruit
stones and seeds, coins, rings, natural  and artiAcial teeth, straw, ears of
grain, pencils, needles, tobacco-pipe fragments, dagger and sword points,
knives, gunshot materials  of all  kinds, fragments  of  dress, of glass,
pigments.
   These foreign bodies are often got rid of, sooner or later, through the
natural channels.  Occasionally, however, they abide long—it may be
for  life—without occasioning serious annoyance,  and  are  afterwards
found to have become isolated within a callous exudate-capsule.
   In other cases, they give rise to various, more or less  perilous  symp-
toms, and not unfrequently prove fatal.  Thus, they may act as  plugs,
or injure in many other ways every variety of organ.  Again, they may
induce and sustain inflammation and ulceration to the exhausting point.
   A certain interest  attaches to the migrations of foreign bodies, as now
and then witnessed in the case of needles, grain-ears, and bullets;  these
being, after a longer  or shorter interval,  discovered or, perhaps, sponta-
neously ejected through suppuration, at parts of the body remote from
the point of  their introduction.  These  migrations  are sometimes the
result of gravitation,  as in the case of bullets.   At other times they are
obviously quite  independent of this motive power.

                            c. PARASITES.

   Under this generic term we comprehend such formations, infesting the
organism both  within and without, as  represent independent  entities,
either from the  vegetable  or animal kingdom. Their investigation belongs
to pathological anatomy in general, but  especially  so, inasmuch as the
presence of parasites  not only implies  previous, but also  engenders new,
morbid conditions.  Moreover, they merit  a place in this chapter because
it is daily becoming more  clear  that they are  not  the production of a
generatio cequivoca out of diseased organic matter, but that  they enter
into the organism from without, and  find there a soil  appropriate for
their subsistence and growth.
   Parasites are  introduced into the organism either as seeds,  as ova, or
in a  more advanced condition,—to germinate, become developed, or grow,
in or upon the organism.  Nor is it less evident that certain pathological
states determine a disposition, not exactly to the generation,  but to the
evolution and redundant growth of parasites, for which  they furnish the
necessary conditions.  Thus,  parasite  plants  (fungi) readily and  com-
  VOL. I.                           17 
258
PARASITES.
monly germinate in particular exudates upon mucous membranes, whilst
upon normal mucous membranes their sporules remain undeveloped.
   Parasites become pernicious in various ways.

            I.  Parasite  Plants (Epiphytes, Entophytes).
   These all belong to the lowest forms of plants, the fungi, and unless col-
lected together in redundant growth, they are too minute to be cognizable
with the naked eye.
   Respecting their origin  by propagation through sprouts and sporules
hardly a doubt can exist,  and as little  as to their  translation  upon and
into the organism; although only in a  few instances has it been possible
to certify this by direct evidence.
   It is  obvious that certain conditions are  requisite for the harboring
and the evolution of these germs.  This  often manifestly  consists in
pathological conditions, and, at the same time,  often in processes of  de-
composition (fermentation, putrefaction).   In the  great majority of in-
stances, however, we are  in the dark  concerning  those conditions, and
the success of our experiments is dependent upon chance.  The former
contingency is  exemplified in fungi upon  muco-membranous  exudates,
sloughs, and upon mortifying patches of the common integument.
   The relation of the vegetable parasite to the concurrent morbid condi-
tion varies.   The latter sometimes stands in that of a pre-existent state,
favorable to the development  and multiplication of the fungi; at other
times the parasite, harbored through  influences unexplained, may become
the cause of textural disease; for example, inflammation, suppuration,
decadence and loss of hair, &c.
   Herewith, the injury they inflict upon the organism terminates.  Still
they may, where they vegetate extensively, become further mischievous
by increasing or  specifically modifying some process of decomposition.
We may instance the fungi of aphthae.
   If we except the torula cerevisiae in the  contents of  the stomach and
intestines, the torula of diabetic urine, and perhaps, Goodsir's sarcina
ventriculi (possibly an infusorium1),  parasitic plants, in man, affect the
common integuments and mucous membranes only.
   With  their  buds  shooting out into  more  or fewer long,  linked,
branched threads, they present the form of the thread-fungus.

       1.  FUNGI  UPON AND WITHIN  THE COMMON INTEGUMENT.
   The most important are :—
   (a.)  The mycoderma intinea favosa  (Schonlein, Gruby).  Shut up in
splitting capsules, it constitutes the skin-imbedded favus.  These fungi
like the torula cerevisiae, present in their most  simple form  roundish or
oval cells,  and these put  forth  buds,  which shoot out into simple  or
branched threads.   The favus-fxmgxxs belongs to the genus Oidium
(Linck), and according to Miiller greatly resembles  the oidium aureum
of wood.  Or, according to Corda, it may,  together with all thread-fun-
guses,  which fructify by simple  separation of their links, and in which
every link may become a spore, be taken, along with yeast funguses  into
the great genus Torula.
         1 [It is now, however, pretty generally admitted to be an alga.__Ed.] 
PARASITE ANIMALS.
259
  There is as yet no certainty as to the part played by  these thread-
funguses.  Attempts at inoculation have hitherto failed, with the excep-
tion of one experiment made by Remak.
  (b.) Fungi in the root-sheath of the hair in sycosis [mentagra, Gruby].
They collect  around the hair  itself within  the root-sheath, and are
marked  by redundant spore-formation.   The spores are  spherical and
the thallus-threads frequently contain in their interior little granules.
  (c.) Fungi in the interior of the hair-roots [Gruby].   In alopecia cir-
cumscripta, areata [porrigo decalvans],  the  falling out  of the hair is
caused by a thread-fungus,  called by Gruby, on account of the minute-
ness of its  spores, microsporum.
  (d.) In  plica Polonica, Giinsburg has  detected,  in  the hair-bulbs, a
fungus which differs from that of favus.
  (e.)  In Pityriasis versicolor, Eichstedt has discovered a thread-fungus.
  Fuchs, Klenke, Helmbrecht, have observed a fungus formation in lepra
alphoides,  and inoculated it with success.
   Langenbeck met with a fungus in crusta serpiginosa.
   Finally, the mould formations  upon  sloughing ulcers,  and in senile
 gangrene,  come under this head.  They are both frequent and copious.

                 2. FUNGI  UPON  MUCOUS MEMBRANES.

    These are very often found upon the mucous membrane of the mouth,
 the pharynx,  the oesophagus,  the intestinal canal, that is  to say  in
 fibrino-croupous,   and  especially in  corroding,   aphthous  exudates.
 Aphthae and diphtheritis of the mouth and throat; croupous exudates in
 the same localities, in florid phthisis; croupous exudates  in the  larynx,
 oesophagus, &c, in the sequel to typhus.
    They are assuredly not  the morbific agent.   The croupous exudates
 upon  which they vegetate  are cognizable to the naked  eye, for those
 familiar with the subject, by  a peculiar character, consisting in a viscid,
 curdlike turgescence, dingy yellow or tawny  discoloration, and a broken
 or jagged  aspect.
    The fungi resemble those of favus.  The thallus-threads are, however,
 mostly much longer, more slender, and  have frequently at their free ex-
 tremity protuberances  replete with minute granules (spores).   They
 often form very compact, felt-like tissues.
    Amongst these funguses  are, no doubt,  to  be  counted the  fungus
 Noma, of  Klenke; those found by Bennett in the sputa and lungs, in a
 case of pneumo-thorax, as  also in the black sordes upon the teeth, in
 typhous patients ; again, those seen upon so-called  typhus-ulcers in the
 intestines; lastly, the mould  such as we ourselves once observed upon an
 old blood-clot, unattached within a bronchial sac.

                   II. Parasite Animals (Siebold).

    Parasite animals are divisible, although not strictly  so,  into ecto-para-
 sites (epizoa), and into  ento-parasites (entozoa).  The former infest the
 surface of the body, the latter its different cavities and parenchymata.
    Some of them are parasitic during their entire existence; others only 
260
INFUSORIA. — INSECTS.
 at certain periods of it.   For this purpose the latter migrate, and enter
 into various metamorphoses.
   Some of them inhabit exclusively certain definite parts  of the body,
 both cavities and parenchymata, others on the contrary occur in various
 regions of the body, and in great numbers all  at once.  All this is con-
 tingent upon their habitudes, and perhaps still more upon the mode in
 which  they obtain access to their place of abode.
   With regard to the  difficult question of their origin and  propagation,
 modern researches in the least promising domain, namely, of the helmin-
 thes, have pretty well succeeded in subverting the older  doctrine  con-
 cerning  the  generation  of  parasites,  and their relation to the  animals
 which  they infest.
   They  get  introduced  into the organism as  ova, as larvae, or even as
 developed creatures ; and wherever they meet  with a nidus congenial to
 their nature, live and thrive upon it.  For this habitation  to last, how-
 ever, a peculiar disposition  on the part of the  subject is no doubt indis-
 pensable.  In the  different parasites this  sort of predisposition differs
 materially.   Much is  assuredly  not required  to incur a  visitation  of
 ascarides.  On the other hand, notwithstanding the extensive dissemina-
 tion of the ova of the helminthes, the disproportionately small  number
 of persons affected with worms; the  circumstance that, under certain
 conditions (for  example, disease), worms for the most  part, if not alto-
 gether, abandon  the individual  they had infested; and lastly, the fact
 that different kinds of  worms are proper to different  animals; testify to
 the necessity of the peculiar disposition  adverted to, existing in persons
 affected with worms.

                           1. INFUSORIA.

   The most frequent are the  vibriones, in purulent  and  other  protein-
 fluids in  the progress of decomposition.  Donne' has detected  a vibrio in
 the pus of chancre, and rated it  beyond its worth.
   In pus?< the vorticella,  and also the colpoda cucullulus (Vogel) occur.
   The trichomonas vaginalis, detecting by Donne'  in the vaginal mucus
 of syphilitic females, is probably not an infusorium, but   a  misshapen
 ciliary cell from the uterus or the tubes.
   Lastly, we have to cite the hcematozoa occurring in the blood; if they
 be not rather the embryones of  worms, which is probably the case with
 many of them.

                             2.  INSECTS.

   Besides the various flies which infest putrid  ulcers with their ova and
 maggots, and the exotic  [still  problematic] oestrus hominis, we have the
flea, the lice, and the bug.
   (a.)  Pulex irritans, the common flea.
   (b.)  Pulex penetrans, the sandflea, common in  the West Indies and
 in South America.  The impregnated female  burrows into the  skin
 especially beneath the toe nails, where the brood gives rise to malignant
 sores.                                                          ° 
INTESTINAL WORMS.
261
   Of lice there are—
   (a.) Pediculus capitis, the head-louse.
   (b.) Pediculus pubis,  the crab-louse, infesting, the scalp excepted,
every hairy part, and penetrating the skin with its head.
   (c.)  Pediculus vestimenti, the  clothes-louse, infesting parts of the
body devoid of hair, and uncleanly vestments.
   (d.) Pediculus tabescentium, the louse  of wasting disease, in  which
it occurs in great multitudes.   The notion, however, that there is a
disease in which lice are generated beneath the skin, is without  doubt
fallacious.
   Of bugs, we have only to mention the ordinary bed-bug, cimex lectu-
larius.

                       3. ARACIINIDA, ACARINA.

   (a.) The itch-mite,  acarus  scabiei,  sarcoptes  hominis, punctiform,
from a quarter to half a millimetre long,  ovoid,  garnished with  trans-
verse, bandlike, dorsal striae, and with  central, acuminate warts; ante-
riorly a bristled  proboscis, prolonged  inferiorly  to  a band upon  the
thorax;  four bristly fore-feet  terminating  in  disk-plate,  whilst  the four
hind-feet taper into lengthy bristles.
   It burrows in  the  epidermis, often boring beneath it a canal several
lines long, at the  termination of which   the  acarus is, on a narrow
inspection, discoverable as a minute whitish speck, marked with  a  brown
point.   When the said canals penetrate to the cutis, they engender the
itch-vesicles and pustules.
   Researches  into the natural history of  this mite, together with the
results of extended experience, prove beyond a doubt its relation to itch
as its sole cause.
   The  follicle  mite, acarus  commedonum sive folliculorum,  an elon-
gated  acarus,  from  one-fifth  to  one-third of  a  millimetre  long, and
about  one-twentieth broad, the head having two lateral antennae and an
intermediate proboscis.   The head passes immediately into the  anterior
part of the body, which  occupies about one-fourth of the entire mite.
From it project four  pair of  very short,  thick, conoid, three-jointed
feet, each furnished with three toes.   The  anterior body  passes without
break  into the posterior, which gradually  tapers, but is rounded  off at
the extremity, is  transversely striated,  and contains a finely granular,
brownish mass.
   It inhabits  singly or numerously the hair sacs and  sebaceous  follicles
on  various  parts of  the  person.   Amongst other anomalies,  it  occa-
sionally  displays only six feet,  which no doubt implies an earlier state
of its development.  Its presence is probably  often  of  little moment.
Occasionally,  however, it may, by stimulating the secretion, engender
commedones, or  set up inflammation, and thus give rise to the acne
pustule.

           4.  INTESTINAL WORMS.—HELMINTHES.—ENT0Z0A.

  Restricting ourselves here to the consideration of such as are  peculiar
to man, we would preface our special description of them with the fol-
lowing general remarks: 
262
INTESTINAL WORMS.
  (a.)  Intestinal worms, in their consummated development,  are  all
provided with  organs of generation.  Those in which the latter have
not been demonstrated,  are propagated by buds or by offshoots, if they
be not imperfect, that is, either larvae or diseased animals.  As opposed
to the doctrine of equivocal generation, these facts are important, if we
consider:
  (b.)  The migrations and the attendant  metamorphoses of  the  hel-
minthes.
  The  migrations of the helminthes  consist, first in the search for a
suitable animal to inhabit, and in introducing themselves into  it, when
found, through channels  formerly unthought of.  Secondly, they consist
in abandoning  the animal dwelt in, for the  purpose of casting their ova
under  favorable  conditions, then in passing  through  one  of their meta-
morphoses, and lastly in searching for another animal for their habita-
tion.   They pass, under various  phases  of development, for the most
part through  natural  orifices of the body,  more especially into and out
of the intestinal  canal.  Their  occurrence, however, even in the paren-
chymata, is intelligible  upon grounds  of direct experience.   As illus-
trative  of this, the larvae of cercarioid  trematoda, and  of  the  tetrar-
hynchi, have been  observed to  migrate through  the parenchymata of
mollusca and  fishes.   It is also deserving of notice,  in this  place, that
helminthes may reach, and settle in any parenchyma through the circu-
lating  channels,  probably by boring for  themselves  a passage  into the
bloodvessels of the  intestinal  canal.   This applies to  the nematoid,
thread-like animals found by Valentin, Vogt, Gruby, Ecker,  and others,
in the blood of frogs, dogs, and ravens,  and probably representing the
embryones of helminthes.
   This migration of the helminthes may involve frequent aberrations,
and  these in their turn  many phenomena,  which an extended  inquiry
will  perhaps correctly set down to a morbid condition.   We  refer more
particularly to the encysting, the  atrophy, and the deformity of certain
helminthes; amongst  others, of the  trichina spiralis,  and the  taenioid
cystica.
   (c.)  The metamorphoses  of  the  helminthes, coincident   with their
migrations, are of the greatest interest.  They constitute  a  circle of
generations, which Steenstrupp, following up the investigations of other
naturalists, has pointed  out  in the trematoda (as in  the  medusae, bulb-
polypi, and  salpae).   A parent  animal  produces a brood  altogether
dissimilar to itself, nor identified with it until  after three or  four gene-
rations.   These  intervening generations of larvae—these pro-nutrices
and  nutrices—form without sexual mediation, and are the source of the
numerous fallacies taught by the older helminthologists.
   (d.) All  this  accords perfectly  well  with  the  strict limitation of
certain worms to particular countries.   The most striking  example is
afforded in those two riband-worms, the botryocephalus latus, of Russia,
Poland, Prussia  up to  the  Vistula, and Switzerland;  and  the taenia
solium of the remainder of Europe.
   (e.) On  the  other side, the doctrine of the origin of  the  helminthes
out of intestinal mucus  and the like, has not a single point of  real evi-
dence in its favor.  A disposition to worms exists only  in so far as an 
NEMATOIDEA.
263
organism abnormally nourished  offers to helminthes, introduced into it
from without, a nidus well adapted for their development.
  In mankind the following helminthes occur :—

            NEMATOIDEA,  ROUND WORMS, THREAD  WORMS.

  Filaria medinensis, the  thread  or Guinea-worm, of about the thick-
ness of packthread, whitish, from half a foot to several feet long, at the
broader end obtunded, terminating behind in a pointed curve.   Peculiar
to tropics of the Old World, but  especially to Guinea;  inhabits the sub-
cutaneous areolar tissue, especially of the lower extremities, but  occa-
sionally also of  the scrotum, the trunk, and the throat.   Having spent
its  earlier period out of the body,  it burrows  beneath the skin, where it
tarries  in the areolar  tissue  for a considerable  time (several  months),
after  which  it  again perforates  the skin from  within, in order to  dis-
burden itself  of its offspring, or in order, it may be, to migrate for this
purpose altogether.   These proceedings are attended with inflammation
and ulceration, and  great caution is recommended, in any attempt to
extract the worm, to avoid tearing  it;  either the elapsing brood or other
contents of the worm, having an erosive property which tends to aggra-
vate the said processes.  It would seem  that, as yet, none but females
have  been observed.  Accordingly these  must  have introduced them-
selves in the impregnated state.
   Trichocephalus  dispar,  the  hairhead  or  whip-worm;  filiform;  the
anterior part hair-like,  the posterior part considerably  thicker; from
one and a half  to two  inches long; of distinct  sexes.  The male is, at
its  posterior  part, spirally convoluted,  and  its  penis contained in an
elongated, funnel-shaped,  violet-colored sheath.  The posterior part of
the female is  not spiral.
  It infests the caecum, singly, and also frequently in multitudes [espe-
cially, it is true, in the  dead  bodies  of persons who  have died of pro-
tracted typhus or similar  diseases], without occasioning  any extraordi-
nary symptoms.  The females are  loaded with ova, which are,  however,
not developed in this locality.
  Ascaris lumbricoides, the cylinder worm, a widely disseminated intes-
tinal worm, from five to twelve inches in length, cylinder-shaped, taper-
ing towards  both extremities, especially  towards the  anterior; having
four longitudinal  striae, two of which are more strongly pronounced;
densely marked with  transverse  striae;  semi-diaphanous, so  that  the
intestinal canal and the organs of  reproduction  are transpicuous.   The
head, divided from the body by an annular groove,  displays three little
nodules, or rather valves, which encircle the mouth.  The caudal extre-
mity, especially in the male, is incurvate.  Sexes distinct, ^ the male
being smaller and narrower, and having at the caudal  extremity a thin,
capillary, sometimes  double penis.  The  female is larger, and exhibits
at its upper  third a fissure from six to eight millimetres long, as  the
orifice to the  organs of generation, which  contain ovaries  and oviducts
of enormous length.
  It infests the  ileum, often in extraordinary number, in groups and con-
glomerate masses.  A brood is never  met with; the ova, therefore, be- 
264
NEMATOIDEA.
come hatched extraneously to the human body, to remigrate thither after-
wards, as the living brood.  It gives rise to the well-known worm symp-
toms.  The perforation of the intestine, however  [migration extraneous
to the intestinal membranes], and its sequelae are, to say the least, ex-
tremely rare.
   Oxyuris vermicularis  (the  Ascaris vermicularis  of Rudolphi), the
hook-tail, maw-worm;—a little, thin, white worm.   Sexes distinct.   The
male very rare and small, from one  to one and a-half millimetres long,
with spiral convoluted tail: annulate ;  with a tail terminating in a fine
transparent point.   The head of either displays a transparent swelling,
which under  the microscope appears  as a wing-like membrane.
   It inhabits the colon and especially the rectum, occasioning both here
and in the vagina,  into which  it creeps, an intolerable  itching. ^ As  it
is never accompanied by a brood, it  probably migrates  as the impreg-
nated female.
   Strongylus gigas [Pallisadenwurm].   Giant strongle;  a very large,
cylindrical worm, of from five inches to three feet long, and  from two
to six  lines  in thickness; when recent, of a fine red color.   Sexes dis-
tinct ;  the male smaller,  more tapering towards both ends;  annulate,
with shallow, longitudinal grooves ; head  obtuse, with  six papillae; at
the tail extremity,  a funnel-shaped pouch, out of which protrudes a very
thin penis.   The female,  larger,  with obtused caudal extremity, and
near it the vulva.
   Inhabits the kidneys; is rare both in man  and in brutes [found in the
dog, the wolf, the marten, the horse, &c]
   To these may be added the  following nematoda and nematoid pseudo-
parasites, some of them being  very rare, or even but  once met with.
   The filaria bronchialis.   \_Hamularia  lymphatica, Treutler—II. sub-
compressa B., once seen by Treutler in a  degenerated  bronchial gland
in the human subject.]  Filaria oculi humani [in the liquor Morgagni
and in the cataractous lens,  Gescheidt, Nordmann].  The filaria in the
blood [Klenke]; the anchylostoma  duodenale [Dubini, in  the  duode-
num] ;  the  spiroptera hominis [Barnett, in the urine] ; the dactylius
aculeatus [Curling, in the urine].  Finally the encysted nematoda.
   Trichina spiralis, an incarcerated worm, which one might be tempted
to class intermediately between the  nematoda  and  the cystica, were  it
not extremely probable that it is only a strayed nematodon which, with-
out  coming  to maturity,  encysts itself, perishes, and cretifies within a
second cyst thrown out from the textures.
   The worm is enclosed within a double cyst, an external one,  mostly
lemon-shaped, and an inner, oval one; the space of  the first, at its two
ends, being Ailed up with  very Ane dark granules.  Both consist  of a
homogeneous, faintly granular structure; the former  being  about one
fiftieth of an inch long, and one ninety-fifth  broad, the latter one seventy-
seventh long.  In the inner cyst, amidst a  more or less granular, viscid,
transparent fluid, lies the  worm, perfectly free, and  generally rolled up
in two and  a half spiral  convolutions.   When extended  it is from one
twenty-fifth to one thirtieth  of an inch long, and about one six-hundredth
broad, lumbricoid, thread-like  at both extremities, although more pointed
at the one than at the other.   It  possesses internally a winding canal 
CESTOIDEA.
265
interpreted as intestine, and a granular organ, the designation of which,
as an ovary, is without doubt erroneous.
   Occasionally the cyst contains two, or even three, worms.
   The Trichina spiralis inhabits the voluntary [striated] muscles, and
always  in  vast  multitudes, the  muscles appearing to  the naked eye
studded with little white specks.   The  cysts always lie  with their long
diameter parallel to the course of the muscles.   [Hilton, Owen, Blizzard,
Henle, and others.]

                    TREMATODA, SUCTION-WORMS.

   Especially characterized by their peregrinations and metamorphoses.
   Distoma hepaticum, and D.  lanceolatum, Liver-fluke;  flat,  melon-
seed or lancet-shaped,  soft worms, of a yellowish-white color, with two
suction pores;  one of which is  seated at the head extremity ; the other,
which terminates caecally, at the  belly.   Between the two is the sexual
orifice.   They are hermaphrodites.
   The Distoma hepaticum is the larger, being from four to eight or  to
fourteen lines long, and from one and a half to six broad, with a branched
intestinal canal.
   The Distoma lanceolatum, as the  smaller, is  from two to four lines
long and about one broad.  Its intestinal canal  is bifurcated.
   Both infest the liver of the herbivora, rarely of man.  The D. lanceola-
tum has only once been met with in  the latter.   In brutes they occur in
great multitudes, obstructing and dilating the gall-ducts.
   Distoma oculi humani.   A minute distoma, once met with in a child
between the cataractous lens and its capsule.
   Poly stoma pinguicola,  Hexathyridium pinguicola (Treutler).  An
inch long and from two to  three lines thick, oval, superiorly convex, in-
feriorly depressed worm, with  six pores  at its head extremity, and  a
larger abdominal aperture  anterior to the tail.   Found once by Treutler
in the fat of an ovarian fat-cyst.
   Polystoma venarum, Hexathyridium venarum (Treutler), probably a
pseudo-parasite.

                      CESTOIDEA—TAPEWORMS.

   These are characterized  by their enduring growth, and  by the great
length to which they attain.  They consist of  a succession of linked
joints, of which the fully developed, sexually mature, hindmost ones be-
come cast off in greater or  lesser  series ;  whilst at the neck, fresh joints
are continually being reproduced. As in these,  again, a brood is rarely
seen associated with the old individuals, whilst  the  separated, sexually
mature joints so frequently become ejected, it is probable that the em-
bryones become developed  externally to the animal they  infest, to re-im-
migrate subsequently.
   In mankind there occur:
   The  Tcenia solium, T. vulgaris, T. cucurbitina, the  ordinary tape-
worm, long-jointed  tape-worm,  chain-worm; a white, or  yellowish-white
worm, twenty feet long and beyond it, anteriorly thin, roundish,—pos- 
266
VESICULAR  WORMS.
teriorly flat, and from three to six lines broad,—jointed.   The joints are
flat, square, towards the  distal end  more  and more oblong-square, re-
sembling gourd-seeds with truncated  apices.  At the right or left margin,
often  alternately, is  seen a wartlike projection marked by a pore with a
raised brink.  This is the orifice of the sexual organ, which represents a
cavity dendritically branched throughout the joint.   The head constitutes
at the very thin anterior termination,  a  nodule-like intumescence, with
four lateral, black points in relief.   There are four suction pores ; and,
between them is seated upon a slightly raised circle a double  coronet  of
hooklets.   The annulate neck is studded with numerous  lime-corpuscles
of the most various size (vide  Cystica).
   Inhabits the small intestine in man, almost in all districts, except where
the botryo-cephalus  occurs.  The belief that it only occurs singly in man
is quite adverse  to experience.  We  have discovered nine of them in the
corpse of a lad.   It  occasions  the well-known annoyances, but no visible
anatomical mischief.
   Botryo-cephalus latus, taenia lata, the broad  or broad-jointed  tape-
worm, resembles  the last  in  many  points, equalling  it in length, and
being in like manner jointed.   Its joints are usually broader  than those
of the  T. solium;  this alone, however, cannot  pass for  a  diagnostic
mark.  The wartlike projections  are not, as in the other worm, seated
at the margin, but at the centre of the  ventral  surface.   Their pore
leads  to a branched rosette-shaped,  sexual organ.  The  head, differing
from  that of the T. solium, exhibits no suction-pores, but two  longish
grooves.
   Inhabits the small intestine in  man, but is strictly limited  to  Russia,
Poland, Prussia [trans  Vistulam],  Switzerland,  and to  the South  of
France.  If it occur elsewhere  it is assuredly imported  from one  of
those countries.
   It  rarely parts with single joints or links, but usually with a greater or
lesser chain of them.

                    CYSTICA.—VESICULAR WORMS.

   In  the formation of their head, these  resemble  tape-worms to such a
degree, that even in 1836  Johannes Miiller proposed to unite them in a
single order, with two subdivisions.  Light has, however, been  since
thrown upon the subject, which warrants us in going a step further, pro-
nouncing these cystica with tape-worm heads to be in truth nothing more
than  errant cestoda, which, owing to their deviations, have  sickened, de-
clined,  and remained sexless.
   The  lime corpuscles found  upon them, and especially upon the cysti-
cercus, are the  same as  those occurring upon tape-worms.   They have
been  erroneously held to be ova,  and in reality rather represent an outer
skeleton formation.   These cystica, within textures, are almost always
distinctly encysted; that is, shut up within a  capsule effused from  the
textures.   In free spaces,—for  example in  the ventricles of the brain,
this is not the case.  This adventitious outer cyst is not to be confounded
with  the cyst proper to the animal itself.  They frequently perish, espe-
cially through inflammation of the external  cyst,  being either mechani- 
VESICULAR WORMS.
267
cally crushed by, or corroded  and destroyed in, the  product.   In the
sequel, the complicated contents of the outer cyst, after having suffered
many changes, progressively thicken, and eventually cretify, en masse,
within the shrivelled capsule.
   The unequivocal proof of the previous existence of an animal in such
obliterated cysts is furnished by ddbris of the animal cyst; by hooklets,
from the coronet of hooklets, which have  resisted the corrosive agency;
and lastly, by the presence of the lime corpuscles before alluded to.
   In man  occur:
   The cysticercus cellulosus, consisting of a conical, snow-white, trans-
versely rugous body, and of a  vesicle which constitutes its  caudal ex-
tremity. The vesicle is oval, spherical  or square,—in muscles,  cylindrical,
parallel  to the  muscular fibres,—and of  the size of a pea or a haricot
bean,—in  rare instances, for example, in the ventricles of the brain, of
a hazel-nut.  When the animal is retracted into  this vesicle, it  appears
as a white, spherical, solid  body, seated  somewhat  eccentrically on  its
inner surface, whilst upon the  vesicle itself is observable, externally, a
delicate point-like fold  or depression at the same spot.  When the animal
is external to the vesicle, a condition easily brought about by puncturing
the vesicle, and pressing the hardish  spherical  body between the finger
and thumb, a pore becomes perceptible which leads to the interior of the
animal pouch.   Taking the size of the caudal vesicle at the ordinary
one of a pea, the animal itself, that is the trunk, would about equal the
diameter of the vesicle, both together measuring from six to twelve lines
in length.   The neck  is short, very thin, and, like  the body, wrinkled.
Upon it is seated the largish, bulb-shaped,  or rhomboidal  head, upon
which there is at each angle a circular suction-cup ; and midway between
these a proboscis, cone-shaped in  its protruded state, with, at  its ex-
tremity, a coronet of hooklets consisting of a double row [about thirty-
two in all], which, when retracted, pack  up into  a  funnel-shaped cup.
The two circles of hooklets are identical in shape ; those of the outer
circle are however much smaller than the  others, whilst both are so dis-
posed that the larger and smaller hooklets alternate with each other.
   The above-mentioned transversely  wrinkled, anterior portion of the
creature appears as  an  almost  structureless, feebly striated  membrane,
to which a  profusion of fine, black-contoured molecule adheres.   It  is,
moreover, studded with a multitude of roundish or oval, whitish, smooth,
sharply  contoured, shining, lesser  or bigger corpuscles, of  from one-
eightieth to one-thirtieth of a millimetre  in diameter.   They are  most
numerous about the  middle part; near the neck  and head their  number
greatly diminishes, whilst, close to the caudal vesicle, they suddenly and
entirely  disappear.  They lie superimposed in several layers, those  of
the outer stratum being only loosely adherent to the animal, so_ that they
may be very easily  scraped away.   Treated with hydrochloric  or with
acetic acid, they dissolve under the copious development of carbonic acid,
leaving an  organic  base-substance behind.  In the solution,  oxalic and
sulphuric acids create a precipitate.
   The caudal vesicle consists of the same homogeneous, indeterminate,
granulated mass, besprinkled with countless small and larger fat-molecules.
The contents of  the caudal vesicle consist of a  watery, neutral fluid,
holding but a scanty portion of albumen. 
268
VESICULAR WORMS.
   Wherever the cysticercus  occurs in textures, it is  inclosed within a
second  cyst  of fibrous  texture.   When magnified it  appears as  a deli-
cately-fibred membrane, permeated by delicate  blood-vessels, and easily
rendered transparent by acetic acid.   Where the cysticercus occurs free
within a cavity,  as within the  ventricles  of the brain, it is uninvested,
showing the outer cyst, in other localities, to be adventitious.
   When the creature perishes, as frequently happens from disease of the
outer cyst, the caudal vesicle becomes semi-opaque, collapsed, its contents
turbid, displaying the said lime-corpuscles and hooklets, which, together
with a granulate mass, are found floating  in its fluid.   The entire crea-
ture softens and liquefies, afterwards  condenses, and eventually settles
into a cretaceous concrement.   Meanwhile the outer cyst shrivels and
dwindles into a thick-membraned  capsule, for  the  isolation of the said
concrement.
   The cysticercus cellulosus occurs in  the brain, in the striated muscles,
including  the heart,  and in the  areolar  tissue.   It  also   occurs, free,
without its  outer envelope, in the ventricles of the brain, and  in  the
chambers  of  the  eye.  It sometimes  occurs in the muscles and brain
simultaneously, in great multitudes.
   Even in the brain  it  is usually borne imperceptibly.  When present
there in great numbers, however, it often occasions vertigo, and the case
has  happened of its proving  fatal by setting up inflammation in its
vicinity.
   Echinococcus hominis acephalocystis (Laennec).  The relation of both
to each other, and the import of the last-named animal in particular, will
become manifest from the following description:
   (a.) Echinococcus.—Within  a sac of fibroid texture is  inclosed a soli-
tary, independent,  thoroughly  distended  vesicle,  containing  a limpid,
serous fluid;  or  else inclosing, as a parent vesicle,  other  similar vesicles
of various size, in various numbers, spherical or flattened by mutual com-
pression, either floating at large in the contained  fluid, or  sessile upon
the inner  membrane of the said parent.   Its size varies  from that of a
vesicle just cognizable, and as big as a poppy- or a millet-seed, to the magni-
tude of a  goose's egg and more. In number it may amount to hundreds,
so that  the serous contents of the parent vesicle are reduced to a mini-
mum.  Generally speaking, the lesser filial vesicles are sessile, whilst the
larger ones are free.
   In very voluminous sacs it is common to find that the parent  vesicle
appears to be wanting.   Either it is mixed up with the younger vesicles,
split up, collapsed anddissolved into scattered shreds, or else it has dis-
appeared  in the  excessive attenuation consequent upon its  enlargement.
   In their unimpaired vegetation, these vesicles are filled to distension,
are elastic, and  impart  to the touch a sense  of tremulous fluctuation  as
does the parent  cyst  replete with them [hydatid tremulousness].   They
consist of a  substance  resembling coagulate albumen, separating into
several  layers, partly diaphanous, partly white and opaque, frequently
accumulated in  the  inside to  considerable thickness, and  into gibbous
projections.  Moreover, they contain a limpid serosity identical with the
contents of  the parent cyst.   When the vesicle is punctured  this fluid
gushes forth in a column, and  on an incision being made, the parietes of 
VESICULAR WORMS.
269
the vesicle become suddenly inverted.   The substance of the latter is a
stratified, homogeneous, very fine-granular,  structureless  mass, whilst
their contents exhibit a few lustrous fat-drops, some scattered  or agglo-
merate, elementary granules, and glebous coagula.
   These vesicles occasionally contain  others similar, of  a third,  and the
latter again in rare instances of a fourth generation.
   On a narrower  inspection of the inner  surface of  these  vesicles, we
perceive in many of them, a whitish, opaque, gritty efflorescence, whilst
with the aid of the microscope we  here  discover densely-nestled animal-
cules, which prove, by the  most various changes of shape, that they long
continue to live  on in the dead subject.  A few of them are even found
free in the above-mentioned fluid.
   This entozoon is from one-ninth to one-third of a  millimetre long, and
from one-twelfth to one-fourth of a millimetre broad.  It has  a  taenioid
head, with four  lateral suction-pores,  and  a proboscis garnished with a
double coronet of hooklets.  The head is distinguished from the  thicker,
spheroid trunk,  by an annulate indentation.  From the proboscis a longi-
tudinal striation runs to the posterior  part, and, commencing from these
striae, the body  of the creature is transversely  striated.  The posterior
termination is a transverse cleft, in which is inserted a cordlike forma-
tion, by whose  means the  creature maintains its seat upon the vesicle.
Between the striae of the trunk are spherical or  oval, limelike corpuscles,
resembling those upon the cysticercus.
   In its developed state the creature  appears in the above form.  It is
met with, however, under  various other  shapes.   Thus it appears  as an
elongated sphere, in the centre of which the coronet of hooklets  appears
perspicuous when the  head is retracted.  Or it assumes the shape of a
heart, or of a pitcher, or even of a horse-shoe.
   The abode  of this echinococcus in mankind is, according to our own
experience, invariably internal to, and never external to, the vesicles.
   (b.)  Acephalo-cyst.  Under this term we at  this  day understand no-
thing beyond  those vesicles which we  have just described as being inha-
bited by the echinococcus, but which are in some instances sterile.   The
above name has been given to this formation in order to designate that
supposed independent vitality which the absence of organs still renders
problematical.  The  Acephalo-cyst, which Blainville reckons amongst
the  "monadaires," and Kuhn  compares to  Agardh's protococcus, with
its multiplication by buds, is in our own opinion not to be held separate
from the echinococcus, although  the  precise relation  between the  ani-
mal and the vesicle is by no means clear.
   The relation of the primary acephalo-cyst [the echinococcus-vesicle]
to the outer cyst, is analogous to that of  a new growth incapsuled  by
exudation from the surrounding textures.
   1.  W. Griffith has examined acephalo-cysts and their contents.  The
transparent fluid, of 1-008  sp. grav., coagulated readily by heat or nitric
acid, and contained an inconsiderable amount of fat.   A thousand parts
yielded fifteen parts of solid ingredients,  principally common salt. They
left 0-85 per cent, of this salt, a little sulphate of soda, a trace of phos-
phate of lime, and some albuminous extractive matter, but neither choles-
terine nor alkaline phosphates.  The envelopes of the hydatids left, when 
270
VESICULAR WORMS.
dried, a brown residuum, which dissolved with a deep brown color when
boiled with hydrochloric acid, but was not again precipitated on the ad-
dition of an alkali.  When moist, they dissolved in hydrochloric and in
nitric acid, but the solutions were precipitated neither by ferro-cyanide
of potassium, nor by tincture of galls.  Nothing was dissolved by boiling
them in water, for neither  by tannic nor by nitric acid  was either any
precipitate formed, or the fluid gelatinized.  When boiled with carbonate
of potash, the dried membranes were dissolved with brown  coloration,
but without any accompanying development  of sulphuretted hydrogen,
nor any precipitation on the addition of an acid.
   Acephalo-cysts, together with the creatures that infest them, are  ex-
tremely liable to  destruction, through hypertrophy,  atrophy and conse-
quent perforation of their external coat; but most particularly through
inflammation of the latter with its products.
   It is not a rare thing to find,  within a sac, individual vesicles imper-
fectly filled,  or collapsed, with walls transparent, tumefied, gelatinized,
or even degraded to a smeary mass.   The contents of such vesicles  are
turbid.  They consist partly of fat-globules with a fine pulverulent point-
molecule in great abundance, and the ddbris of broken  up echinococci.
Occasionally  this  conversion affects  most,  if not  all of  the vesicles.
They burst or rather open out, owing to the increasing tendency to  dis-
solution, until at length the entire contents of  the parent cyst are ren-
dered turbid.
   The inflammation of the  outer sac, a  frequent occurrence, is impor-
tant.  It bears the character  of  inflammation of  a  sero-fibrous mem-
brane, and throws its products, for the major part, upon the inner surface
and  into the cavity of the cyst.
   It is in many instances to be regarded as a fortunate event, leading as
it does to the disruption and extinction of the acephalo-cyst, with its in-
habitant animalcules, and in  due  time to the shrivelling and decay of the
entire sac.  The contact of the acephalo-cysts with exudate, and the re-
ception of the latter through endosmosis into the walls and cavity of the
acephalo-cysts appear to be  amongst  the most ordinary causes of their
dissolution.   After the effusion, gradual  resorption of a portion of  the
contents—that is, of the original serous fluid, and of  the exudate—fol-
lows, whilst another portion  thickens  to a grayish, unctuous chalk-pap,
and  eventually cretifies altogether.   The sac shrivelling commensurately
with the diminution of its contents, becomes obliterated  in such wise as
ultimately to inclose a mass consisting of variously superimposed residua
of acephalo-cysts (echinococcus-vesicles) and of the said chalk-pap or con-
crement.
   It is not unfrequent for an intense inflammation to terminate in ulce-
ration of the  sac, so that an abscess, inclosed within the implicated paren-
chyma, takes its place.  This, together with  consecutive suppuration in
neighboring  textures, may lead  to the opening of the sac into another
adjoining one;  or to  its opening externally: or into one or other  of the
great serous  sacs; into the intestinal canal; into the urinary cavities or
passages; the gall-ducts, &c.  The direction in  which  such an abscess
empties itself decides the question as to  the favorable or  the unfavorable
issue of the case. 
BLOOD DISEASES.
271
  The echinococcus and acephalo-cyst are particularly frequent in the
liver, less and less so in the subperitoneal, areolar tissue, and in the peri-
toneum, in the omentum, in the striated muscles, including the heart, in
the brain, in the spleen [mostly in concurrence with others in the liver],
in the kidneys; very rare in the lungs and bones.
  Not unfrequently they occur in several organs simultaneously.   Thus
they will infest in vast numbers both the peritoneum and the abdominal
viscera.   In magnitude the sacs may attain, or even exceed the diame-
ter of a foot.
   The echinococcus-cysts may become  perilous through  their volume;
and, when present in great numbers, prove fatal through exhaustion and
general wasting, as also through the aforesaid inflammatory and suppu-
rative processes.

                        SPURIOUS  PARASITES.

   As such are to be reckoned all those foreign bodies reputedly or really,
accidentally or designedly, conveyed upon or into the human body; but
which are proved either not to infest it  in reality, or to be of a nature
even manifestly to preclude a parasite existence.
   We have to bring into this account not alone animal creatures, and
various parts  of animals and of plants; but also misshapen, diseased tex-
tural parts  of the organism, or products of disease.   Such are:
   1. Animals and parts of animals dead or alive, really voided by stool
or  rejected by vomiting, such as the larvae of flies  received into the
stomach with  food in a state of decomposition, or accidentally or design-
edly added to the matter so evacuated.
   2. A great variety of other bodies of the descriptions adverted to.
   Amongst the spurious parasites of the present day we may cite—
   (a.)  The trichomonas  vaginalis of Donne",—probably a  misshapen
ciliary cell.
   (b.) Biceras rude (Rudolphi), repeatedly recognized as the  undigested
seeds of mulberries.
                BLOOD DISEASES-DYSCRASES.

   Humoral pathology is simply a requirement of common practical sense;
and it has always held a place in medical  science, although the limits of
its domain have, no doubt, been variously circumscribed or interpreted
at different times.   Of late years it  has met with a new basis and  sup-
port in morbid anatomy, which, in the  inadequacy of its discoveries  in
the solids to account for disease and  death, has been compelled  to  seek
for an extension of its  boundary through a  direct examination  of the
blood itself.
  Not alone has pathological  anatomy demonstrated  the  existence  of
blood diseases in unlooked for detail; it has at the same time solved a
problem of the weightiest import.  It has, we think, decided in favor of 
272
BLOOD DISEASES.
 a humoral  pathology, by demonstrating a primitive anomaly of blaste-
 mata ; by demonstrating the endogenous impairment of the blood within
 the vascular system, in the inflammatory process, as the basis of the varia-
 tions in exudates [blastemata] ; lastly, by demonstrating the dependence
 of local morbid action upon pre-existent impairment of the general circula-
 tion.   Our attention will be here directed to diseases of the blood  in its
 totality, and to local dyscrasial processes, with inflammation at their head,
 only in so  far as these offer the basis and  starting-point for consecutive
 disease of the entire blood-mass.  It is  remarkable, however, and no less
 important for practice than for science, that the essential forms of these
 local dyscrasial  processes,—perhaps of all local dyscrasial disease,—
 occur, likewise, as primitive affections of the  entire blood-mass.  This
 is proved by the varied  character of the products of the inflammatory
 dyscrasial process, and a comparison in detail of  these  products with
 anomalies of the general blood-crasis.   Thus, primitive pyaemia, fibrin-
 crasis, sepsis of  the blood, severally occur independently of all  local
 beginning, and of all infection.
  There are, indeed, two ways of investigating and recognizing blood-
 diseases : first, the anatomical examination of the  blood in the dead sub-
ject, or of blood obtained during life through spontaneous or artificial
 hemorrhage; and secondly, chemical analysis.   Both kinds of investi-
 gation should be  supported, and the  results controlled, by a concurrent
 examination of the secretions and excretions, of the general condition of
 the solids, and of new-formations, especially of such exudates as are the
 offspring of inflammation.
  In fine, both kinds of research should go hand in hand.  For, although
 a deeper insight into the changes suffered by the blood may be reserved
 for  chemistry, it must needs be based upon  sound  anatomico-humoral
 premises.   Up to the present day chemistry has not taken this duly into
 consideration, so that as  yet this science cannot be said to have far ex-
 celled the achievements of a circumspect anatomical survey, notwithstand-
 ing the limited resources at the disposal of the latter.
  Upon the chemical pathologist we would strongly urge an unremitting
prosecution  of his researches.   We would recommend him to direct his
labors  more particularly towards ascertaining the precise character of
the  impairment suffered by the  proximate ingredients of the blood, and
of the anomalies impressed upon its elementary composition.  The  inte-
rests of haemato-pathology would after all, perhaps, be best served by the
examination, in the  above sense, of blood taken from the  dead subject,
the  diagnosis of the case having previously received the light of a general
post-mortem examination.
  Our own task in these pages will be limited  to  establishing a  purely
anatomical pathology of  the blood; we shall therefore restrict ourselves
as nearly as possible, to anatomical facts, although without neglecting to
avail ourselves of the collateral support  of such chemical data as may be
relied upon at the present hour.                                   J
 _ It is the business of pathological anatomy to determine both the  phy-
sical properties  of the blood in its totality, and also the relative quantity
and more especially the  quality,  of its more immediate components' 
BLOOD  DISEASES.
273
The two main components which come peculiarly within its province are,
first, those essential form-elements, the blood-globules ; and secondly, the
spontaneously separating, coagulating, solidifying fibrin,—that  compo-
nent which, owing to its varying tendency to become organized, is, in an
anatomical sense, the most important of all.  We will here  summarily
refer  to what has been said in the introduction  to the  doctrine of blaste-
mata and to the section  on exudates, and then proceed to treat of blood
diseases in what would appear to be their most natural order.  The  sub-
ject is,  however, so intimately allied to that treated of in the chapters
referred to, that a certain amount of repetition will,  perhaps, be unavoid-
able in  the following pages.
   Affections of the blood are, like those of the solids, either primitive or
consecutive.   And again, the former, equally with the latter, suggest an
inquiry  as to whether  they result from an immediate influence of the
morbific agent upon the  blood, or are determined by the nervous  system,
as the actual percipient, alienated both in matter and  in function.   This
question can, however, hardly affect us in this place, since the latter  view
mainly  rests on speculative grounds, and upon the fact that obvious injury
to, or sensible anatomical disturbance of, the nervous system  sooner or
later results in disease of the blood.
   The  latter are determined in very different ways by anomalies in the
solids.   Thus, the  hindered eliminating  activity of an organ occasions
retention of effete matter in the blood ; an abnormal plastic process influ-
ences the blood crasis, directly or indirectly, through the anomaly in the
interchange  of  matter.   Take  for example, the infection of  the blood
within  the range of an inflammation.
   To diseases of the solids,  as local morbid processes in the broadest
sense, affections of the blood stand in a twofold  relation:
   1.  The anomalous crasis is a pre-existent  one—the primitive  affection ;
the local disease a  localization thereof—the  secondary affection.   The
point of localization, apart from the effect  of concurrent external influ-
ences, is determined by  a specific relation of the crasis to certain organs
presided over by the nerves.   The forms it assumes are chiefly  those of
hyperaemia  and stasis—inflammation, absolute stasis,—exudation, or,
without the  latter, a product-formation completed within the bloodves-
sels ;  for instance, spontaneous coagulation  of diseased fibrin, pus-forma-
tion within a greater bloodvessel or within the capillaries of an organ.
   The relation of the various erases to the organs and textures, nay,  even
to particular sections of organs, is  manifold.  Thus, the croupous fibrin-
erases evince a very marked preference for  the mucous membrane of the
air-passages, and for the lungs  themselves; the typhus-crasis,  for the
mucous memb'rane of the ileum; the exanthematous erases, for the  com-
mon integument and for mucous membranes.
   2.  The anomaly of the general crasis is consecutive ; that is, the con-
sequence of  a local disease, and especially of local  dyscrasial  processes,
whereof the  products are taken up into and  affect the general blood-mass.
This  happens—
   (a.)  Through resorption of the effused products by means of the  lym-
phatics, or immediately into the veins.
  vol. i.                          18 
274
F I B 111 N - C R A S E S.
   (b.) Through reception into patent bloodvessels.  This process includes
the reception of products thrown out into the cavity of larger bloodves-
sels,—pus, for  example.
   (c.) Most of all, through the off-flowing, and the return into the veins,
of plasma degraded in the local process, in a manner corresponding with
the quality of the exudate. [See " Relation of the Inflammatory Process
to the Crasis."]
   It  is, however, to  be understood that, neither  does a dyscrasis neces-
sarily always become localized, nor a local dyscrasial process invariably
give rise to a consecutive dyscrasis of the entire circulation.  In the for-
mer case, a certain degree of intensity of the dyscrasis is no doubt requi-
site ;  in the latter case, the reception of a sufficient quantity of plasma,
degraded in the manner aforesaid by the local process, or else of a hete-
rogeneously diseased,—for example, of an ichorous or septically consti-
tuted—plasma  is indispensable.
   Blood diseases are, moreover, either protopathic,  whereby we mean
developed out of the normal crasis, or deuteropathic, that is created out
of another anomalous crasis.  [Meta-schematism.]  Deuteropathic erases
occur in the simplest manner, as impoverishment of the blood in one or
more  ingredients, drained away by excessive deposition into textures or
upon  membranous expansions.
   Blood diseases are  both acute and chronic, and they are marked ac-
cordingly by the rapidity or by the slowness of their  career.  This is
contingent upon  the character of the  dyscrasis, upon its  grade,  and
upon  the significance of the organ in which it becomes localized.
   They issue:
   (a.) In transition  to  the  normal blood-erasis.   This occurs  under
various conditions, for the most part obscure; for example, under the re-
turn of the free function  of an organ, under exhausting localization of
the dyscrasis in one  of the aforesaid processes, or in some secretion.  In
this way tuberculosis and  cancer may lose their  general import and be-
come  local affections, which either go on vegetating under the normal
condition of the blood, or  enter into a retrograde metamorphosis.
   (b.) In transition to another anomalous  crasis [meta-schematism].
Such  transitions are  multiform, some of them appearing to be necessary
conversions when the original crasis is  at  its acme, others to represent
the final wearing out of some component of the blood.  With respect to
others, however, we  are still in every way completely in the dark.
   (c.) In death, not  only through overwhelming localization  in vital
organs, often coupled with palsy of their function;  not only through ex-
haustion of organic matter and of the powers of life, owing to redundant
local  production; but  also, in many instances, through unfitness of the
dyscrasial blood for  the upholding  of processes essential to life, for the
maintenance  of nutrition  generally, but especially  of respiration and of
the energies of the entire  nervous system, both central and peripheral.

                         1.  FIBRIN-CRASES.

  The fibrin-crasis occurs in several most important forms and varieties
which the term hyperinosis—as designating a frequent but by no means 
FIBRIN-CRASE3.
275
necessary and invariable excess in the quantity of fibrin—does not suffi-
ciently characterize.   It overlooks the far more important, and, for the
most part, very marked feature of quality.  However certain may be the
excess of fibrin, its qualitative deviation becomes more and more distinctly
pronounced in proportion as in the series of fibrin-erases the forms recede
from  the characters of true fibrin.   This, with the  exception of a few
hints thrown out by Andral, has been hitherto ignored.   In this  qualita-
tive anomaly, however, the varieties  of the  fibrin-erases  are founded.
Each  may be,  and very often is, a hyperinosis, at the same time.   Still
the qualitative  anomaly is the essential point; and it may, in a hypinotic
crasis—that is, in poverty of fibrin—cling to a minimum of fibrin, and
with it manifest at once that peculiar tendency of fibrin-erases to locali-
zation, and  a marked peculiarity in the product.
   These different fibrin-erases are, as in the sequel their  special  delinea-
tion will show,  manifested by certain anomalies of appearance and struc-
ture.   They are distinguished in common by the proneness of their fibrin
to coagulate, and by its deposition, more or less pure, within the vascular
system, from the heart to the capillaries downwards.  They are, more-
over, marked by their localization in inflammations which are  wont to
affect very vascular organs, such as the lungs, mucous and serous mem-
branes, and areolar tissue.
   The fibrin-erases, including pyaemia, tend  more particularly to prove
that all those changes which the plasma undergoes in local dyscrasial in-
flammation, and its products or exudates, take place within the general
circulation and  by virtue of its  own intrinsic  relations, not  through any
local reciprocation between the  blood and the textures inflamed.
   The fibrin-erases constitute, generally, the  so-called phlogistic blood-
admixture,  against which, conformably with  the view of a  quantitative
exaltation of the vital process, the lancet has ever  been opposed.   Yet
amongst the processes in question, far-sighted pathologists have always
discriminated some in which much bleeding appeared not  only needless
but even mischievous ; we refer more particularly to the croupous pro-
cesses.   That in these, a qualitative  deviation in the constitution of the
fibrin plays the  part chiefly deserving of attention, is proved not only by
the more obvious anomalies of aspect and of structure before alluded to,
but also by—
   1.  The proneness of these erases to become localized,  even where the
amount of  anomalously constituted  fibrin in  the blood is very  inconsi-
derable ; as, for instance, in the secondary croupous erases emerging out
of the typhus-crasis ; in the tuberculous crasis, in which the last  particle
of fibrin is expended in the deposition (localization)  of tubercle.
   2.  The reaction of  many  congenerous exudates  upon  their parent
textures,—this reaction consisting in softening and corrosion.
   3.  The wasting  attendant upon hyperinosis, or the predominance of
fibrin, that element of the  blood commonly held in an especial manner to
preside over general nutrition.   Here the alienation of functional  activity
can only be interpreted as qualitative.
  We have already adverted to the localization of the fibrin-erases.   In
relation to  this, it is  a  question equally interesting and opportune, 
276
FIBRIN-CRASES.
   whether the erases regarded as hyperinoses, in inflammations, be deter-
   mined by the latter, or constitute the primary and fundamental disease ?
   The view received  in  France, tends to demonstrate the dependence of
   the crasis upon the local inflammation ;  in other words, the symptomatic
   character of the crasis.  With the setting in of the inflammation and its
   increase, the amount of the fibrin is supposed to become  augmented.
      We are fully convinced that an inflammation obviously called forth by
   external causes may, by the abduction of endogenous, and the resorption
»  of exuded products, give rise to a corresponding  crasis, which Avill be-
   come augmented in proportion as the inflammation increases in intensity
   and extent.  On the other hand, we believe that spontaneous stases are
   localizations of a crasis, and stand to it in  a dependent—a conditional—
   relation.  This opinion is based upon the following facts:
      1.  Every crasis [by no means the fibrinous erases  alone, to which, as
   the so-called phlogistic, we might  be  disposed to concede this preroga-
   tive] is capable of localizing itself in the shape of inflammation ; take for
   example, the typhous and the exanthematous erases.   The objection that
   inflammations, and  especially pneumoniae,  arise during  the progress of
   typhus, is met by the  fact that those inflammations with the character
   of a  fibrin-crasis  are  based upon a  fibrino-croupous crasis—in other
   words, that they are  the localization of a fibrino-croupous  crasis into
   which the typhus has  become converted.   Genuine typhous pneumonia
   (pneumo-typhus) does  not develope a  fibrin-crasis, any more than does
   typhous inflammation  of the intestinal follicles or  of  the  mesenteric
   glands.
     An objection of considerable weight against the  opinion promulgated
   by Andral, is furnished by pneumonia, the very process  commonly con-
   current with the most  marked hyperinosis.  We believe that ordinary
   pneumonia [with fibrinous product] is, for the most  part,  the localization
   of a pre-existent, that  is, precursorily developed crasis, a crasis charac-
   terized by  an incontestable relation to the lungs, and  to the mucous
   membrane of the air-passages.  Such a view does away with the paradox
   that inflammation of the lungs, a disease which, in its intense form, at-
   tacks and disables large sections of the lung, should uphold so enormous
   a development of fibrin,  whilst other lung  diseases  lead to erases of the
   very  opposite kind—in  a word, to venosity [Hypinosis,  Albuminosis,
   Cyanosis].                                       ^
     2.  Lastly, the argument derives force from the general disturbance
   which always  precedes a localization,  seeming to  bear witness to an
   alteration in the crasis.   And to this may be added, the nature of the
   causal influences, which  appear to be rather  general than local.   We
   may instance epidemics,  climate, weather,  &c.
     Fibrin-erases become, for the most  part, primitively developed under
   the conditions of a free respiratory function.  Of  this fact  striking ex-
   amples offer in the tuberculoses, and the  setting in of  croupous and of
   tuberculous processes after childbirth, that  is to say, after the release of
   the thoracic spaces and of the lungs, resulting from  deliverance of the
   womb.
      Certain fibrin-erases are primary, and distinguished by their localiza-
   tion  upon the mucous   membrane of the  air-passages  [laryngeal 
SIMPLE  FIBRIN-CRASIS.
277
tracheal, bronchial, pulmonary croup], upon serous and synovial mem-
branes, and in  large accumulations of areolar tissue.  Others are secon-
dary, that is, the  consequence or the conversion of  other erases, for ex-
ample,  of the  typhus-, of  the exanthema-, of the cholera-crasis.   In
these, a qualitative anomaly of the  fibrin predominates, as shown  by
this, that, even where but an inconsiderable amount of fibrin  becomes
developed, localization takes place, and this of an unwonted kind, as, for
instance,  upon the mucous  membrane  of the  intestinal  tract, of the
urinary passages, of the gall-ducts, &c.   Others,  again,  are primitive,
spontaneous, or even  consecutive affections of the blood  determined by
infection with analogous substances.  They are often epidemical.
   Above  all other erases, the fibrin-erases, like the fibrin-exudates, are
never thoroughly pure.  Every portion of morbid fibrin has, associated
with it, another portion of less diseased, or even of normal fibrin.
   The products of the localized fibrin-erases  [endogenous coagulations,
and especially  exudates engendered  by inflammatory stasis] are partly
organizable [designed for regeneration, or expended in hypertrophy],
partly unorganizable, liquefying, corrosive, purulent, or ichorous.  These
exudates  correspond  so  completely with the nature of  the coexistent
fibrin-coagula within the  vascular system, that the character of the one
may with safety be inferred from an  acquaintance with the other.
   It is interesting that coagulations in the left heart, that is out of arte-
rial blood, are not alone more decidedly compact, but also more  frequent
than those out of  venous  blood.   As  evidence of this  we  may cite the
incomparably more frequent globular vegetations in the arterial cham-
bers of the heart.
   As yet, chemical analysis has contented itself with demonstrating the
quantitative excess of fibrin in the blood.  According to  our  own  re-
searches,  however, investigations  are urgently requisite which  have for
their principal  aim to determine the qualitative impairment of the fibrin.
An augmentation of the fibrin is always coupled with a diminution in the
amount of blood-globules, and, as  chemists maintain, at  the same time
with an increase in the proportion of fat present  in the  blood.  This
certainly, however, does not apply to every fibrin-crasis.
   Fibrin-erases attended  with  great exudation, frequently  bequeath, as
consequent upon the exhaustion of fibrin, a condition of hypinosis [defi-
brination], and of hydraemia.  They eventually  prove fatal from this
source,  if the patient have escaped the deadly influence of paralysis of
the organ of localization, or of spontaneous coagulation in important
sections of the vascular system ; for instance, in the ramifications of the
pulmonary artery.  The highest grades of dyscrasial fibrin-constitution,
finally degenerate  into sepsis of the fibrin, and, indirectly,  of the entire
blood-mass.
   The crasis may   also terminate in  restoration of the normal  crasis,
through conversion of the morbid excess of fibrin into nitrogenous sub-
stances, eliminated with the urine  and perspiration.   The fibrin thus be-
comes largely converted into excrementitious matter. 
278
CROUPOUS  CRASIS.
    (a.)  SIMPLE [ORGANIZABLE  FIBRIN-YIELDING] FIBRIN-CRASIS.

  It is the attendant upon inflammations with an organizable exudate,—
that is, an exudate susceptible of textural conversion.   It comprises the
inflammations of wounds healing by the first intention ; many inflamma-
tions of glandular organs, and of serous and synovial membranes  which
terminate, not in purulent liquefaction of their products, but in gradual
resorption or in textural conversion  of the  latter,—or in the case of
pneumonia, in obliteration of the pulmonary texture.
  The product of these processes—that is, the exudate-fibrin determined
by  these  processes—answers  to the  character   of  fibrin  2.   [See
"Fibrin."]
  The crasis consists in this: namely, that the fibrin, besides  increase
in quantity, usually manifests, within the bloodvessels,  the  character of
the exudate-fibrin just adverted to ; in other words, those qualities which
fibrin acquires in certain  processes of inflammation.   The  tendency of
fibrin to  coagulate is sometimes aggravated into spontaneous coagulation
within the vascular system.
  The coagula are white, or yellowish-white, compact, frequently holding
enclosed a notable quantity of serum.   Under a closer inspection they
appear as a glebous,  fibro-glebous blastema,  here  and there delicately
Abrillated in  wavy curls.  Through this are interspersed numerous black-
contoured, spherical or Abre-drawn nuclei, along with scattered, dull-
granular  nuclei, and  nucleated  cells.  All the nucleus-formations are
rendered more sharply deAned by the influence of acetic acid,  the blas-
tema itself becoming turgescent  and transparent.   [See "Fibrin 2."]
  To this category belong not  a few of the  so-called vegetations or
flbrin-coagula within the heart's  cavities, not a few coagula  in  bloodves-
sels of  every calibre  down to  the  capillaries,  perhaps also  the  intra-
arterial stratiform coagula, and those endogenous  depositions which are
the primitive source of phlebolites.
  Unless these coagula—produced during life—be, in a state of minute
subdivision, taken  up  again into  the  blood,  they  enter into a textural
conversion.
  The crasis is either a spontaneous, primitive,  or else  a consecutive one
engendered by infection of the blood with a product of a corresponding
kind.
  The dead subject is marked by great cadaveric rigidity, by Arm, deep-
red muscles, by tense, dry areolar tissue, and by retarded lividity and
decomposition.

           (b.) THE CROUPOUS CRASIS [PIORRY'S HiEMITIS.]

   The  croupous crasis occurs under several forms, which  at  the same
time represent various  gradations of disease of the fibrin.   Amongst
them we And, on  the  one side,  the  most marked hyperinoses •  on the
other, a scanty proportion of Abrin, but that deeply affected in quality.
This is  manifested first by its augmented coagulability, by  a greatly in-
creased tendency to deposition in the shape of intra-vascular coagulation 
CROUPOUS  CRASIS.
279
[in the capillaries, as capillary phlebitis], and, lastly, by acute processes
of exudation.
   Both the intra-vascular coagula and the exudates are distinguished by
their indisposition to become organized, by their early liquefaction, and
very often by their corroding, solvent effect  upon the textures.   Both
are opaque, yellow, or of a greenish-yellow, and contain fat.  The adhe-
sive property gradually diminishes.
   To the latter, namely, the exudates, must be reckoned some, exhausting
by their volume and abundance, others  inferior in  quantity, but indi-
cating, by their tendency to liquefy and by their reaction upon the tex-
tures, the deep impairment of the Abrin.
   They  are  often idiopathic, but  more  frequently  consecutive erases,
emerging out of others,—the  typhous, the exanthematous, &c.  In the
former case they are marked  hyperinoses; in the latter case they are
determined by inflammation,  and the infection of the blood with  conge-
nial products.   They constitute the so-called haemites of Piorry.
   In their processes  of exudation, they evince a  preference  for the
mucous  membranes, especially of the respiratory and of the digestive
tracts, as also for the serous and synovial membranes.

                         CROUPOUS CRASIS a.

   It is characterized by the following relations of the Abrin in its coagu-
lation and exudation.
   The coagula—engendered in the death-agony—are, in the heart, either
clod-like,  cord-like, more  or less compact  masses  prolonged into the
bloodvessels, or where the energy of the heart's systole has been broken
long prior to death, and the mortal struggle protracted, membranaceous,
lining the heart's cavities or insinuating themselves in the shape of fangs
amongst the trabeculae.  When developed during life, they appear, in
the heart, as the liquefying so-called  globular vegetations; in wide-
calibred bloodvessels, as cylindrical and plugging, or as membranaceous,
coagula loosely attached to the internal  membrane  of the bloodvessel;
in capillary  ranges, as obstructions of the texture varying in circumfe-
rence.   They are either pure  Abrin  or  contain  more or  fewer blood-
globules, incorporated with them during the act of precipitation. ^ In the
former case, they are.marked by their opacity, by their  dull white, yel-
lowish, or yellowish-green coloration.  In the latter  case, they are like-
wise opaque, but, according to the amount of contained blood-globules,
more or less reddened.
   A closer inspection shows the coagula to  consist of a glebous-like,
Abro-glebous blastema, or of  a faintly striated, membranous basement,—
like the inner, the fenestrate,  bloodvessel membrane, bestrewn with point-
molecule,  with  numerous  granulated,  grayish nuclei or  nucleus-like
formations, and with similar  granulated  cells.  All  the  nucleus  forma-
tions are  uninfluenced by acetic  acid,  except that a slight shrinking
takes  place, and that they  acquire a somewhat sharper outline.  Not
unfrequently the entire  coagulum seems to consist of these nucleus- and
cell-formations, along with a proportion of point-molecule.   [See  " Fi-
brin 3."] 
280
CROUPOUS  CRASIS.
  The metamorphosis of these coagula consists for the most  part  m  a
tolerably rapid liquefaction of the blastema to a puriform, tenacious fluid
holding the aforesaid form-elements in suspension.
  The exudates, reflecting  the hyperinotic condition of the blood, are
generally very abundant, even to  the exhaustion of the Abrin.   Ihey
are reddened in a degree conformable with the amount of extravasated
blood which they have incorporated,—as, for instance, in hepatization of
the lung.   Or they are of a grayish-yellow with a slight shade of green,
and opaque.  Their metamorphosis consists, possibly with textural trans-
formation of any organizable portion, in disintegration  and liquefaction
of the blastema to a  pus-like, tenacious fluid.  [See  " Croupous Exu-
date a."]

                        CROUPOUS  CRASIS /3.

  Its characters are nearly those  of the  former, as regards the outer
aspect of the coagula and of the exudates, only more strongly developed.
Thus, the opacity of the coagula and of the exudate-flbrin is more consi-
derable ; their coloration,  where they do not include blood-corpuscles,
more decidedly of a greenish-yellow.   Their metamorphosis consists in
rapid, puriform liquefaction.
  More narrowly scrutinized,  the coagula are found to consist of a  Ane,
dense point-molecule,  of nucleus- and cell-formations in different degrees
of completeness and  of assimilation to the  pus-cell.  These are  held
together through the  instrumentality of an amorphous bond-mass.   En-
gendered during life, they  break  up—the blastema  liquefying—into a
tenacious fluid, in  which the elements specifled are held in suspension;
and which, in  proportion  as the cells  predominate, more  and  more
resembles pus.  [See " Fibrin 4."]
   The exudates, corresponding in  character with the usually hyperinotic
condition of the blood,  are generally very copious, exhausting,  of a
yellowish or a greenish-yellow tint, imperfectly adherent to the exuda-
tion-surface,  rapidly  liquescent to  a puriform  fluid, and of a  form-
composition identical with that of  the coagula.   [See Croupous  Exu-
date £.]
   In both the coagula and the exudates, the basement or blastema  con-
necting the form-elements  has lost  the Abrillation so characteristic  of
coagulating normal Abrin,  and even  the glebe-like structure.
   Certain conditions  are common  to both varieties of the croupous crasis
[a  and /3]; to the  latter, however, they apply in a higher degree.
   Both become localized in the shape of  exudatory processes upon the
mucous membranes, especially of the respiratory  tract;  in  early youth,
in the larynx and trachea ; at a later period, in the bronchia; and from
the period of puberty to the end of life, in the lungs [as laryngotracheal,
as  bronchial  croup, and as  croupous pneumonia].  Upon the mucous
membrane of the womb, as also upon the great  serous sacs, especially
the peritoneum, with or without  congenerous puerperal metritis, they
become located, as puerperal processes; in the  synovial sacs, as  acute
rheumatism;  again, as endocarditis  and inAammation of bloodvessels;
lastly, in the areolar tissue, the pia mater, the spleen. 
CROUPOUS  CRASIS.
281
  They also become localized as the  metastatic deposits  of capillary
phlebitis.
  The high  grade of the internal dyscrasial influence is no doubt the
cause why a protracted stasis is not  requisite for product-formation;
why, therefore, the  exudation takes  place very rapidly; and why, not-
withstanding the  great bulk of the exudate and the lax and vulnerable
nature of the textures, it is not hemorrhagic ; in other words, why it is
not attended with any extensive laceration of the bloodvessels.   There
is little doubt that the pneumoniae stated by Hodgkin to enter at once
into yellow and rapidly liquefying hepatization, belong to this class.
  By long contact, the deliquescent coagula and exudates frequently
exert a solvent, corrosive  power upon  the  textures.   In  this manner
they  determine fresh  inflammation, ulcerous loss of substance, phthisis
of the organs, secondary  phlebitis,  pulmonary abscess, phthisis of the
peritoneum, of the pleura, and, along with  these, of the abdominal and
thoracic parietes.
   Or  again, they become re-absorbed, or  else, owing to  the changes
attendant upon their disintegration,  they undergo, together with partial
absorption, fatty conversion, usually followed by inspissation and crete-
faction.
   One further phenomenon here flnds its elucidation, namely, thegnilky
blood.  This has  been witnessed in  pneumonia and  peritonitis, and  we
have  ourselves encountered it in a developed form in pneumonia, and in
very intense inAammation of the spleen.  Such blood has been found to
contain an excessive proportion of fat;  it is, however, questionable whe-
ther this be the  sole cause of the phenomenon.  We believe the latter
to be due rather  to the disintegration of croupous Abrin within the cir-
culation, in other words, to the suspension of the  point-molecule [the
molecular Abrin] in the blood-serum.  It is very possible, indeed, that a
fatty  condition of the blood may contribute to  produce the milky ap-
pearance ;  and not improbable that in some cases of a different kind,  for
example, in the blood of dram-drinkers, it may be the sole cause.
  The rigor mortis manifests itself in the inverse ratio of the magnitude
of the effusion, and the same inverse relation obtains between the latter
and  the  intra-vascular fibrin-coagula.   The blood is in  part loosely
clotted;  for  the  most part fluid ; owing to simultaneous loss of  serum
through exudation, tenacious ; and of a dark cherry-red [defibrination].
It forms, in every  variety of organs, dirty-red hypostases ; death-patches
become rapidly and extensively developed; the  liver is dark-colored.
The  muscles are  lax,  the parenchymata  collapsed,  flabby, lacerable,
moist, and where there is no hypostasis, pallid.

               CROUPOUS CRASIS y.   APHTHOUS  CRASIS.

  In  the croupous erases hitherto described hyperinosis commonly pre-
vails ; in the crasis we are now entering upon, the  amount of fibrin in
the blood is for the most part scanty.   By so much the more significant
must  be  the anomaly in the quality of the fibrin and in  the general
crasis, and we shall presently see this to be really the case,  if we extend
the idea of this crasis in a natural order beyond that constitution of the 
282
TUBERCLE-CRASIS.
blood proper to ordinary aphthae as affecting the mucous membrane of
the mouth.
  The exudates  appertaining  to the croupous  erases before described
occasion destruction of the textures  only after long-continued contact
with them, and in their secondary phase of disintegration.^  In the aph-
thous exudates this effect  is  produced at once, and as  it would seem
during the process of exudation itself.
  The exudates  are yellow, greenish-yellow, dingy gray, opaque, tough
products, which, upon superficial expansions, coagulate in a pseudo-mem-
branous form, and,  together with the textures, rapidly break up.   They
are very often remarkable for the exuberant epiphyte-formations [thread-
funguses] which take root  in them.   The disintegration manifests itself
in various forms, doubtless connected most intimately with the grade  and
with the modification of the crasis, from simple  corrosion with secondary
reactive inflammation in the vicinity [aphthae],  down to fusion to a vari-
ously discolored, fetid, ichorous  pulp, or to a tough or a friable slough,
that tears like soft agaric.
  With this the  crasis  has attained the phase of a putrid decomposition,
a sepsis, a necrosis of the fibrin and of the general circulating fluid.
The blood is discolored and contains partly tough, partly pap-like,  dis-
colored,  ichorous, coagulate fragments—as  exemplified in  diphtheritis,
sloughing tonsils, puerperal putrescence of the  womb, septic  dysen-
tery, &c.   The seat of such processes is above all in the mucous mem-
branes,  especially of the alimentary tube, of the urinary bladder, of the
female sexual organs and  their follicles; in open wounds and sores, in
areolar tissue, in common integument.   Amongst them may be reckoned
thrush  [diphtheritis];  certain  exudation-processes upon  the  mucous
membrane of the intestinal canal, especially of the colon [as a form of
dysentery], and of the uterus after delivery ;  corrosive fibrin-exudates
upon the mucous membrane of the urinary bladder ; upon external  and
internal sores ; muco-membranous ulcers, especially upon the base  of the
typhous ulcers; white  gangrene of the common  integuments  [hospital
gangrene].
  The aphthous  crasis is often  idiopathic.  It  is, however, no less  fre-
quently consecutive upon other anomalous erases, and upon the typhous,
the  typhoid, the exanthematous in  particular.   The blood, reduced in
quantity, presents the characters  proper to those erases;  the few coa-
gula themselves, the characters of excessively croupous fibrin.
  The  dead body  is  collapsed, devoid of rigor.  The death-patches
become speedily discolored to russet and green.   Muscles,  flabby, pale.
Parenchymata, collapsed, friable.   The  blood,  wasted, dusky-red, fluid,
with a few villous, broken  coagula, marked by opacity, toughness,  dis-
coloration, and septic disintegration.


                      (c.)  THE TUBERCLE-CRASIS.

  Although there are, no doubt, tuberculoses purely local, a tuberculosis
extending  through  several organs, or even through one  entire organ  is
invariably the offspring of a tuberculous dyscrasis. 
TUBERCLE-CRASIS.
283
   The latter  is for  the  most part developed out of a fibrin-crasis.   In
 the  dead  subject, a hyperinosis of the blood may not be  ostensible.
 Nay !  owing to the frequent and voluminous processes of exudation  at-
 tendant  upon the course of a tuberculosis, a poverty in fibrin is perhaps
 more likely to reveal itself after death.  Excess of  fibrin has, however,
 been demonstrated,  in such cases, by the chemical examination of blood
 withdrawn during life, and it may also be inferred from the extent of
 the tuberculous deposition.   Still the hyperinosis is far from being ade-
 quate to account for the disease.  It is the qualitative  anomalies of the
 fibrin that must determine its tuberculous nature,—anomalies of  quite a
 peculiar kind, which, as we shall  see, may modify every one of the
 fibrin-erases referred to into the tuberculous.
   The gray tubercle answers to the  character of the simple fibrin-crasis.
 [See " Gray Tubercle."]
   The opaque, yellow, lardo-caseous tubercle, marked by its proneness
 to undergo softening, answers to the character of the croupous-crasis.
 [See " Yellow Tubercle."]
   We have remarked of the products of the fibrin-erases that they are
 seldom  unalloyed.  The same observation  applies  to the products of
 the tuberculous crasis.  The products of the  one  always occur inter-
 mingled with elements of the other ; and tuberculous products may even
 include more  or less of organizable elements which form into textures in
 the ordinary way.
   Again, the transitions of the individual tubercle-crasis from  one to
 another  are obviously brought about step by step.    The croupous tuber-
 cle appears but rarely as the primitive tubercle.  It is  generally based
 upon a pre-existent gray tubercle, and the croupous tubercle  appears as
 an aggravation of the simple form.
   In the fibrin-erases a minimum of fibrin suffices  for the groundwork of
 a qualitative impairment, and this in its amplest sense applies to tubercle.
 The smallest proportion of fibrin present in the blood takes on the taint
 and becomes expended, up to the point of complete  defibrination, in the
 deposition of tubercle.
   Still  these  said erases by no means serve to throw much light upon
 the nature of  tuberculosis.  They must needs involve a peculiar—a tu-
 berculous—modification, the existence of which is indeed proved by the
 tuberculization of extra-vascular fibrin in hemorrhage, and also of intra-
 vascular  fibrin-coagula.   In this modification must be rooted:
   (a.)  The surpassing proneness of the fibrin to deposition, so frequently
 brought about in quite an insensible manner;
   (b.) The assumption by the deposited fibrin of the particular form of
 tubercle.   The granulation of tuberculous products of inflammation upon
 serous membranes might indeed be ascribed to a separation  of the tuber-
 culous portion, due to its great coagulability.   Still  the very localization
 of the tubercle-crasis, in such minute and sharply-defined are* that little
granule-shaped exudates are the result, constitutes a peculiarity—a re-
markable peculiarity, seeing that the same form of separation—the same
form of tuberculization—attaches to the fibrin of hemorrhage  and to en-
dogenous vascular coagula. 
284
TUBERCLE-CRASIS.
   (c.)  The fact that blastemata  resulting from  the tuberculous fibrin-
erases  do not undergo the  metamorphoses—proper  to  the pure fibrin-
exudates—of textural formation  on the one  side, and of rapid purulent
liquefaction on the other ;  but throw off their  exudate-water in the act
of firm coagulation, and tarry for a while in this crude state of consolida-
tion.   This  respite is of various duration, but at  all events exceeds  both
that proper  to textural conversion, and that common to disintegration,
in corresponding, purely fibrinous exudates.
   As the most marked and obvious phenomena connected with tubercle
must be specified its high grade of coagulability, and its surpassing prone-
ness to deposition,—to the localization of its crasis.  In these are with-
out doubt centred the peculiarities of the fibrin-erases in their tuberculous
modifications.
   If, in relation to these peculiarities of tuberculous fibrin, we take into
account:
   (a.)  The consummate coagulability of arterial fibrin generally;
   (b.)  Its supreme sensitiveness towards heterogeneous substances,  such
as inflammatory products, whose  reception, for example, in arteritis, oc-
casions locally so rapid an obstructing coagulation of the blood-column,
as to obviate  any infection of the general blood-mass  from that point.
[See "Arteritis," vol. iv.]
   (c.)  The ready deposition of fibrin out of  arterial blood,  as stratiform
coagula upon the inner  arterial  surface, a  disease, in  its consummate
form, peculiar to arteries.
   (d.)  The very common localization both of the  fibrin-erases, whether
spontaneous or determined by infection, in  the shape of exudate, or of
endogenous  coagulation within the capillaries of the arterializing organs
[the lungs], and again the  still more marked relation of the tuberculous
crasis  to these viscera.
   (e.)  On the one side, the pre-eminent  development of the pulmonary
organ  as predisposing  to the fibrin-erases in general, and to their tuber-
culous modification in  particular;
   (f.)  On the other side, the pre-eminent immunity afforded by exquisite
venosity  and  cyanosis, against fibrin-erases, more especially the higher
(croupous) grades, and most particularly against  the tuberculous crasis,
—taking, we say, all these circumstances duly into account, we are forced
on to the momentous conclusion that arteriality,  that is, the arterial de-
velopment of the fibrin, pre-eminently constitutes  the cardinal character
of tuberculosis.
   The qualitative impairment of the blood-Abrin  here again, as in the
Abrin-crasis of a higher grade, serves to explain summarily the fact, that
in individuals with blood impoverished in Abrin,—or even generally im-
poverished,—tubercle  continues to become deposited.   It has  been else-
where  affirmed, and it is worthy of repetition here, that in such cases
every atom of tuberculo-dyscrasial fibrin becomes expended in the form-
ation  of  tubercle.   This view clears  up the seeming inconsistency of
affirming tubercle to be rooted in a Abrin-crasis, whilst Aorid tuberculosis
is found to be associated with a deAciency in Abrin.  It is the prevailing
notion of mere excess in Abrin that we would impugn.
   The tuberculous-crasis itself may, by various chances, become modiAed 
PYEMIA — PUS-BLOOD.
285
through a combination with other dyscrasial constitutions  of the fluids,
giving rise,  at least in part, to the several known varieties of tubercle.
  The tuberculous crasis is commonly protopathic.  Frequently enough,
however, it results from other erases.  The conversion of typhus, of ex-
anthematous hypinosis to  the tuberculo-croupous crasis is  frequent, and
of the greatest scientiflc and practical interest.
  The tuberculous crasis results, through exhaustion of the Abrin, in a
defibrinated condition of the  blood,—in  albuminosis.  And, again, the
albumen—upon which the wasted fibrin  may be supposed  to  have  in-
grafted its own morbid character—may take  up the work of exudation
in the shape of acute, albuminous tubercle, of lardaceous  infiltration of
the liver, spleen, and kidneys,—of general albuminuria ;—hydraemia and
anaemia being the final issue.
   The corpses of the tuberculous, responding to the long-continued and
copious expenditure of protein substances upon  tubercle, present general
emaciation, with consumption  of  the fat and  of the bone-medulla;—
flabbiness, wasting, pallor  of the muscles; fatty infiltration of the liver,
spleen, and kidneys ; and  lastly, oedema and dropsy.  The blood, with
a few scanty fibrinous coagula, is fluid, adhesive, dark-red ; or else, with
the exception of very inconsiderable  soft coagula, it is  thin, watery, of
a pale-red,  resembling water in which flesh has been steeped.  Wherever
abundant fibrin-coagula are met with, they present the characters proper
to the fibrin-crasis, often in  conjunction  with tubercle-like  concretions,
which in their elementary composition fully harmonize with the tubercle
of exudation, that is, the tubercle of the  textures.

                        PYEMIA.  PUS-BLOOD.

   This crasis again represents a local pus-production, and also a spon-
taneous primitive pycemia of the  entire blood-mass.
   In pyaemia it is necessary to distinguish two different grades or stages,
in order to bring the various facts into  mutual concord, and  to avoid
contradiction in the characteristic  given of this blood disease.   Those facts
are, on  the one side, the  coagulation and deposition; on the other side,
destruction, of the fibrin.  The latter may become developed, as a higher
grade,—as  a consecutive stage, out of the former.  The higher grade
may, however, set in at once, as a protopathic crasis, without being pre-
ceded by the first or lesser grade.
   In the lesser grade the  blood-crasis is  characterized by quantitative
excess in the production of fibrin [hyperinosis],  which is at the same time
qualitatively impaired.  It is marked by a high degree of  coagulability
and of proneness to separation from the blood-mass,—manifesting itself as
croupous, liquefying fibrin.  These main features of the crasis  illustrate
the following appearances.
   The fibrin-coagula endogenous  to the vascular system, are remarkable
for their opacity, for their varying hues of dull white, of yellowish-green,
of reddish-gray [from enclosed blood].  They are soft, and yet tough—
their contained serum being of a  whey-like turbidness.  A closer inspec-
tion shows them to consist of a glebous basement, with the rudiments  of
fibrils, and  about these a  vast quantity  of fine point-molecule.  There 
286
PYEMIA — PUS-BLOOD.
 are, besides these, nuclei, and nucleated cells the nuclei of which appear
 to resemble in various degrees, up to  complete dissilience, pus-nuclei.
 Sometimes they exhibit little  tubercle-like  congeries, which  consist of
 collected elements of pus.  Having originated  during life,  they soften,
 with liquefaction of the said basement, to a fluid which assimilates to pus
 proportionately to the amount of pus-cells included in the clot.
   This crasis, in its most  developed grade, possesses  the peculiarity of
 localizing itself in many  areae in  rapid succession.  Along with highly
 acute inflammation with purulent effusion upon mucous membranes, upon
 serous membranes, and  in areolar tissue, these  areae appear in every
 variety of organ and of texture, and are generally distinguished for their
 small circumference and their  sharp definition.    They form suddenly in
 the textures as red obstructions, which almost  as speedily  deliquesce
 with sloughing and ulcerous fusion of  the involved textures  to a yellow
 or  greenish-yellow pus.   Wherefore,—as also  owing  to  the lack of
 evidence  of  antecedent  inflammation,—they have  received  the name
 of pus deposits or dep6ts;  of pus metastases.   We have already described
 the attendant anatomical  process, and seen that  these acts  [like others
 brought about under the fibrin-erases] consist essentially in  a spontane-
 ous coagulation of the blood-fibrin in  the  capillaries,  and its immediate
 liquefaction, with  ulcerous corrosion of the  bloodvessel membranes and
 of the contiguous  textures; to which  process, inflammation with  similar
 products, as the encompassing inflammatory areola, supervenes.  Coagula
 of the same nature form in the great vessels, and, in the shape of purulent
 vegetations, also in the heart.
   The blood appears, along with the endogenous fibrin-coagula described,
 as a tenacious fluid of a russet hue.  It is seen spread out in a thin layer,
 and mingled with  little soft particles,  which  turn out to be  aggregates
 of pus-nuclei and pus-cells, along with blood-corpuscles, in a transparent
 clot.
   The dead body, owing to the voluminous separation of coagula, presents
 extensive livid patches verging upon russet coloration; hypostases;  tex-
 tural redness of imbibition; lack of rigor; flabby muscles; friable, doughy,
 collapsed  parenchymata.
   The higher grades of the pus-crasis consist in destruction of the fibrin ;
 attenuation and discoloration of the blood; septic decomposition of  the
 circulating fluid, of a nature  corresponding to the rapid ulcerous  and
 gangrenous up-breaking of textures in the local processes.
   The more intense  is the  aggravation of  the  crasis, the  less  do we
 encounter the  aforesaid  depots.  It  is only in  the  transition  to  the
 higher grades  that we meet with them, obviously breaking  up, along
 with the  involved textures, to a dingy  brown,  coffee-ground,  or olive-
 colored,  collapsing, fetid  pulp.  The  same metamorphosis affects both
 the exudates and their parent strata.   In the highest grade extensive
passive stases affect the decomposed blood, producing necrosis with dark
and hemorrhagic imbibition of the textures.
  The dead bodies of persons  who  have died of pyaemia at this stage,
manifest,  apart from the external and  internal  local  processes__due it
may be, to an  earlier phase—long retention of animal warmth, little
and evanescent rigor, flabby and pale  muscle, more especially discolora- 
PYEMIA — PUS-BLOOD.
287
tion and lacerability of the heart, and rapid decomposition with exten-
sive, brownish death-patches.  The parenchymata are lax, easily torn,
serum-drenched, pale, or of a  spurious redness in various shades, owing
to hyperaemia and imbibition of dissolved  blood-pigment.   The lungs
are the  especial  seat of hypostatic congestion,  with a dark coloration
verging  upon cherry-red or upon brown.   The  blood in the heart and
vascular trunks  contains  scanty, colloid-like,  cruor-holding, red,  and
sometimes  greenish-red, coagula, and is itself of a cherry red, adhesive,
or else attenuate, brownish; having stained the bloodvessel membranes
and the endocardium with its coloring  matter.   Pyaemia is not unfre-
quently  primitive  [protopathic—or deuteropathic, that is arising out of
other anomalous  erases—for example,  the typhous, the exanthematous].
More commonly, however, it is consecutive to the reception of pus into
the blood, or else to infection, brought about in the  various ways, fully
detailed at page 274 of the present volume.
   This  applies to both grades of pyaemia of which  it has  been stated
that the second also occurs independently,  determined through infection
of  the  blood by a foul pus decomposed through  stagnation.   To this
category belongs,  amongst others,  the infection  proceeding from  the
poisoning  of wounds with pus out of the  dead  body.  Darcet  brought
forth the disease by injecting  corrupt  pus-plasma, a  disease into which,
as a purulent sepsis or necrosis of the blood, the minor grades of pyaemia
with hyperinosis  become  spontaneously exalted, probably owing to  the
pus in the blood becoming oxidized in the respiratory process.
   The circumstance that pus  secreted bodily into the canal of  a blood-
vessel,  commonly  produces a  more intense infection than pus-plasma
probably received into the blood by resorption, might lead one to con-
clude that  it is to the pus-cell that pyaemia is attributable.  Nevertheless,
apart from the incomparably larger proportion of  pus received  into the
blood in the former case than  in the latter, the occurrence of primitive
pyaemia  precludes our adjudicating in favor of either the pus-cell or pus-
plasma  as  the causal agent.  Far  more  depends, without any doubt,
upon the quality  of the  pus; and it is  certain that a large proportion of
bland pus  taken up into the circulation proves far less mischievous than
an  incomparably smaller quantity of purulent ichor.   That the pus-cell
taken up into the  blood, or even that  other cell  formations  of larger
size—certain   cancer-cells, for  example—should, by  obstructing  the
capillaries, give rise  mechanically to so-called  depots [metastases] will
scarcely be credited at the present day.
  Pyaemia generally proves fatal, as purulent poisoning: inconsiderable
grades of it, however, are  susceptible  of cure.    This  occurs,  without
doubt, partly through a conversion of  the  pus, analogous to the meta-
morphosis  of fibrin—partly through elimination of the pus in exudatory
processes, especially upon extensive mucous membranes, like that of  the
intestinal tract.  The elimination of pus through processes of secretion,
for  instance, its passage  through the  kidneys, with  the  concurrent dis-
appearance of pus-deposits, is a phenomenon much talked of.   The
pus-cell  both  in the  urine  and  in exudates is  incapable  of  becoming
reabsorbed, and equally so of passing out  of  the bloodvessels, either
into the  uriniferous tubules or  at any other part.   It follows, therefore, 
288
VENOSITY, ALBUMINOSIS.
that pus-cells,  either in the urine or  in  an exudate,  must be  a new
creation out of effused plasma.

           2.  VENOSITY, ALBUMINOSIS.—HYPINOSIS (SIMON).

   This constitution of the blood is characterized by deficiency in fibrin
but preponderance of albumen, and  generally  speaking, also of blood-
globules.  The blood is upon the whole thickish, tenacious,  dark-red,
and contains, if  any, only a few soft, gluey or jelly-like coagula, m
which there is much cruor pent up.
   It has a very extensive domain,  comprising a vast number of special
erases, which  reveal  their kindred nature by the general characters of
the blood just defined, by  the  metamorphoses which many  of them
undergo  in  common, and  by the general sameness of  their products;
whilst again they differ in some  particular  attribute of the latter, and
by specific relations to particular textures and organs [localization].
   Their range comprehends the most important and most perilous, acute
and chronic  diseases;  plethora  [general  hyperaemia],  venosity  of  the
lungs, and heart  diseases, the acute  exanthemata,  especially scarlatina
and measles, the so-called substantive  fevers, chronic rheumatism and
gout, rickets,  typhus, Asiatic  cholera,  so-called  acute  tuberculosis,
Bright's  disease,  and  lardaceous degeneration  of  the  liver,  spleen,  or
kidneys,  mollities  ossium, cancer, the erases  of  acute convulsions, of
tetanus, of hydrophobia,  diseases of the nerve-centres, chronic mental
alienation, hypochondriasis,  chronic  metal-poisoning,  especially with
lead,  narcotism,  Anally the erases  accompanying  atrophy after  acute,
exhausting diseases, the so-called suffocative death-seizures generally.
   To discover the  nature of the special  crasis  in so heterogeneous
states, is reserved for the future, and rather  for chemistry  than  for
anatomy.
   Many acute erases  issue  in septic destruction  of the albumen and
putrid decomposition of the  entire blood-mass.  This  consummation is
especially frequent in the exanthematous and the typhous erases, and in
acute convulsions.  The acute erases  are  moreover liable to frequent
transformations, especially to the croupous crasis and to pyaemia.  There
occurs frequently  an acidifying of the blood, which localizes itself in
miliary eruption  and in acute softening of the stomach.
   The crasis is sometimes protopathic,—habitual, persistent,  ingrained
in the individual, or acute and evanescent.   At  other times it is deutero-
pathic,  or the sequel to exhausting  and  especially  to  deAbrinating
disease.   It is,  moreover, a primitive blood-disease,  called  forth  by
poisons,  by miasma, by contagion, or else it is consecutive  to  disease of
solid parts [for  example, organic heart  disease], and determined  by
neurosis.
   The  products  placed under its control [exudates and new  growths]
are distinguished by an excess of albumen, by very subordinate  coagu-
lability,  by lack  of disposition to become  organized, by persistence at
embryonic grades of structural development.
   A not unfrequent  sequel to extensive exudation is  hydraemia, or, it
may be, tarlike  inspissation of the blood  with anaemia.  The  former 
TYPHUS-CRASIS.
289
becomes developed without any notable serous effusion, the water being
otherwise disposed of in the morbid process.  The anaemia is commonly
due to a shattered condition of the nervous system.
   Several of these acute  erases have a decided relation to the mucous
membranes, and especially to their follicular apparatus, to the lymphatic
glandular system, to the common integuments, to the spleen.  The dead
body presents, especially  in  the acute erases, dark  coloration of the
common integument; rapidly developed, extensive, and very dark death-
patches ; early decomposition; a very marked but for  the  most part
evanescent rigor, and a lax, doughy  condition of the parenchymata.
Hyperaemiae and stases arising in the different organs, not unfrequently
become exalted into hemorrhage.  In the tarlike inspissation of the blood,
the corpse is in a high degree emaciated or rather shrunken, dry,—the
common integument, of  a lead-color, or livid.
   Let us endeavor to submit  the more important of these erases either
singly, or where the distinctions are not very marked, more collectively,
to an anatomical muster.

                            (a.)  PLETHORA.

   It is characterized by excess of blood, by a preponderance of the blood-
globules over the fibrin, by a deep red,  tenacious blood.  It involves the
direct manifestations of venosity in the inverse ratio of the  amount of
blood which the  organism is  capable of arterializing.  It occurs under
two opposite and contrasting relations.   First, in  conjunction with florid
nutrition of the textures, fulness  of muscle, and especially ample areolar
tissue and fat formation.   Secondly,  as a very marked phenomenon in
union with general emaciation,—wasting of the solids [so-called nervous
tabes].  Under the latter  circumstances, it is observable both in very
delicate children, during the flrst months of their life, and in insane adults
[in hypochondriasis, melancholia, &c]
   In the dead body, the general  overloading of the vascular system, and
occasionally surpassing hyperaemia of  various organs, especially  of the
lungs or of the brain, or of the liver and entire portal system, are mani-
fest.   According to the degree of  intensity of the crasis, all of the soft
parts are more or less  deeply colored.   In the emaciated, the  common
integuments exhibit vast patches of a purple, or of a bluish leaden hue.
   Plethora  predisposes  to congestion,  to hemorrhage,  to blennorhoid,
albuminous, and serous exudations of greater or less moment in propor-
tion to their amount and to the importance of the organs concerned.  In
corpulent, square-built [apoplectic] individuals  hyperaemiae of the lungs
are frequent.   In these the plethora often of itself, but more commonly
through acute  serous  effusion into  the bronchia  and lung-cells, proves
speedily fatal.  Moreover, the plethora occasions dilatation of the heart,
with  subsequent,  progressive augmentation of its  substance  [hyper-
trophy].
                       (b.)  THE TYPHUS-CRASIS.
   It compasses the entire nature of typhous disease, and is at the root of
all its phenomena, whether of substantive change or of functional dis-
turbance.
   VOL. I.                          19 
 290                     TYPHUS-CRASIS.
                                    \
   The typhus-crasis is marked by the destruction—the diminution—of
 the  Abrin, and the comparative preponderance of the blood-globules.
 The typhus blood is in various degrees fluid, and of a deep purple color.
 It forms, if any, but scanty, loose, soft, and humid, deliquescent coagula,
 reddened by the imbibition  of pigment-holding plasma.
   The corpses of typhous individuals are remarkable for the deep, dingy,
 bluish-gray coloration of the common integument, for the deep purple of
 the death-spots, for  the dark russet hue and the rigidity of  the muscles,
 and for the dryness  of the areolar tissue.  The serous  membranes, and
 especially the peritoneum are of a dull gray, lack-lustre, and occasionally
 suffused  with a tenacious humor.   All the textures in contact with blood
 appear discolored from imbibed haematin, of a peculiar shade, verging
 from violet color upon brown.
   In the next place, the multifarious local hyperaemiae have to be noticed.
 They are due to the paralyzing influence of the blood upon determinate
 ranges of the nervous system, either at the periphery or at the centres.
 Foremost amongst them are local hyperaemiae of the mucous membranes,
 of the lungs, of the brain, and its membranes, of the spinal  cord, of the
 common  integuments.   They often  display the attributes  of so-called
 hypostasis.   Upon  mucous  membranes they frequently degenerate into
 hemorrhages, which occur also, although far more rarely, in parenchymata,
 for example, in the brain.
   The typhus-crasis manifests a  very marked relation to mucous  mem-
 branes, especially to the lymphatic glands and to the spleen.  In middle
 Europe it is the mucous membrane of the intestine and  especially of the
 ileum, rarely the bronchial  mucous  membrane  with the lungs and the
 bronchial glands; in the North, it is rather the last  mentioned, namely,
 the respiratory tract; in the South [in pest-typhus], it  is the peripheral
 lymphatic gland system, in  which the  crasis becomes localized.   In the
 form of a typhous inflammation it determines, in the  follicular apparatus
 of the ileum and in the mesenteric glands, a peculiar marrow-like product,
 which, in intense cases, closely resembles medullary  carcinoma.
 ^  The very variable consistency of the typhus-substance points to varia-
 tions in the typhus-crasis itself;  to different degrees of plasticity in the
 typhous  blood-plasma.
   Pus-formation, we have  to observe, is alien to the genuine typhous
process whether general or local.   Wherever it does  occur, it is founded
 in a degeneration or change in the typhus-crasis, of which we have to say
 a few words.  No other crasis offers such manifold interest  in reference
 to degeneration or conversion.  Not alone are there several conversions of
 the kind, but they are remarkable for an impress the exact reverse of the
 original  typhus.  The recognition of these phases and their interpreta-
 tion as degenerations or transformations, are not only of the greatest
 scientiflc interest, but also of the most obvious practical utility.   These
 changes  resolve themselves  into the  following.  They are more or less
 demonstrable in the  sanguineous fluid, as also more or less proclaimed in
 corresponding local processes.
   1. Conversion to the croupous crasis.
   2. Conversion to pycemia.
   3. Begeneration to acute  softening [acidification of the bloodl
   4. Begeneration to gangrene [Sepsis,—necrosis of the blood]. 
TYPHUS-CRASIS.
291
  1.  Conversion to the croupous crasis.  A fibrin of a constitution cha-
racteristic of the croupous erases forms in the blood.  Perishable coagula
[vegetations, plugging clots, so-called capillary phlebitoids] originate in
the heart, in the greater vessels, in the capillaries; but, above all, exu-
dative processes, upon mucous membranes.  Those croupous inflamma-
tions  of the mucous membrane lining  the tracheal canal,  the oesophagus,
the stomach and intestines, the  female sexual organs, as also  croupous
pneumonia, all belong to this type.  Again, similar processes upon serous
membranes,  the yellow,  fibrinous, crumbling   products by which  the
typhous infiltrations of the mesenteric and Peyerian glands are  modified.
  The exudates are wont to exert a solvent influence upon their  parent
strata, deep corrosions of the mucous membranes beneath  the exudates,
more  especially at the glottis and epiglottis, being not at all uncommon.
  This conversion takes place at various periods of the typhous process—
even  at a very early stage.   It is  deserving of notice that a vast number
of cases in point happen at the  commencement  of epidemics of cholera,
a disease in whose typhoid [so-called reaction-] stage croupous inflamma-
tions  are so frequent.  [See "Exanthematous Crasis."]
   The conversion  of the typhus-crasis to the tuberculous—the tuberculo-
croupous—crasis belongs to the same class.  Its localization  generally
attaches to  the lungs in  the shape  of lobular—not unfrequently of a
comprehensive lobar pneumonia;—pneumonic tubercle-infiltration.
   2.  A second conversion of the typhus-crasis, kindred with the preceding
one, is that to pyaemia and local pus production. It occurs, for the most
part,  at a later period than the one just referred to, often complicating the
last stage of the local typhus-process upon the mucous membrane of the
ileum, and protracting  itself into a sequela to  the typhus.  Examples
hereof are the pus-deposits in the typhous patches upon the mucous mem-
brane of the  ileum, and in the  infiltrated mesenteric glands; the pus-
producing  areolar-tissue  inflammations ;   the  purulent exudates upon
serous tunics; the circumscript, suppurating coagulations in the capillary
system of the lungs,  the spleen, the  kidneys;  the  boil-like obstructions
of the capillaries in the substance of the mucous membranes and of the
outer skin.
  3.  Begeneration to the  acute softening process, that is, to a crasis in
which the  latter is founded, and which is localized in softening of the
stomach, &c.   We believe this process to be a peculiar one, quite distinct
from  putrid decomposition and its characteristic, gangrenous sloughings.
That  which concerns us here occurs as black, or  Indian  ink-colored
softenings or  meltings of the  textures in  an acid fluid, especially in the'
ccecal sac of the stomach, on the left side of the oesophagus, in the lungs,
upon  the mucous membrane of the coecum, and  in the urinary bladder.
  We believe this  process to be derived from the blood in the capillaries
of the parts referred  to, and to be due to an acidification of the blood-
mass,—to the presence of a free acid in the blood:
  (a.) It is developed out of a hyperaemia and  stasis in the implicated
organs, and in point of fact, out  of the blood engaged in the stasis, which
experiences the first effect of the liberated acid  upon itself, in the shape
of inspissation and coagulation to a black, pitch-like, friable mass, destruc-
tive of the walls of the vessels and of other contiguous textures. 
292
EXANTHEMATOUS  CRASIS.
   (b.) The reaction of the structures softened is invariably acid.
   (c.) Our view seems to derive support from the determination of  the
 blood under these circumstances to the coecal sac of the stomach, which,
 with the spleen, appears to us to perform the office of a de-acidifying
 apparatus to the blood-mass, for the immediate secretion of the gastric
 juice and in behalf of the hepatic function.
   (d.) A very frequent appearance  associated with the impending soft-
 ening, is that of a miliary eruption with acid reaction of the contents of
 the vesicles.
   4.  Begeneration to sepsis ; putrid-crasis.  Primary gangrene of  the
 solids.   It occurs either very early,  or only as a sequel to typhus.
   The  blood  and the dead  body exhibit  the peculiar changes to  be
 described in another place.
   Where the putrid character is early developed, the faint impression in
 its localization, especially with respect to  plasticity of its products, is
 remarkable.   The Peyerian gland-groups  are turgid  with sero-albumi-
 nous  infiltration, lax, and, together with  the  mucous  membrane of the
 ileum, generally ecchymosed.
   As the local manifestation of this degenerate state,  sloughing takes
 place in  parts exposed to hypostasis and pressure, for instance, in the
 sacral region, at the trochanters, &c.  This is not all, however: hyperae-
 miae and stases  become developed even in parts beyond the  range of
 hypostasis, leading incontinently to  mortification of the textures,—for
 example  noma of the cheeks, sphacelus of the external sexual organs in
the female.
   All these degenerations may become localized in the typhus-ulcers,
leading,  as will  be seen, in  the account given [see vol. ii.] of  the local
typhus-process in the  intestinal membrane, to  a destruction  overstep-
ping the limits of the textures, and frequently to perforation of the intes-
tine.
 _  Other sequelae of the typhus-crasis are protracted albuminuria [Bright's
 disease], anaemia [with wasting], hydraemia [(Edema, Dropsy].


                  (c.) THE  EXANTHEMATOUS  CRASIS.

   Its domain, viewed from the anatomical side is a very extensive one.
 However, we might wish to limit this crasis to scarlatina and measles, a
number of acute blood diseases naturally cluster around them become
localized upon the greater  mucous  membranes, and not unfrequently,
 especially in epidemics, produce exanthemata presenting  more or less
 analogy with genuine measles, or pure scarlatina.  Amongst them  are
 some which determine a  more or less plastic, albumen-loaded, coagula-
 ting or  colloid-like, thinly purulent, almost  serous product upon mucous
 membranes; exudatory processes which bring the muco-membranous
 texture into a state of dissolution; Asiatic cholera; numerous puerperal
 affections; acute diarrhoea, especially in children;  nay, even exanthema-
 tous typhus ;  in fine, many  substantive [exanthematous] fevers without
 exanthema.   At the uttermost limits of this  domain are  placed blood
 diseases, associated with tonic spasm and convulsions,__with affections 
EXANTHEMATOUS  CRASIS.
293
of the nervous centres.   Last of all, acute tuberculosis.   In the pre-
sent section, however, we shall only speak of the exanthematous crasis
and of those nearest allied to it, leaving the remainder  to  be discussed
in separate  chapters.   The  crasis  in question is  the  most distinctly
marked in scarlatina; and it is here  that we have the best opportunities
for studying it in the dead  body.   In degree, the  crasis of measles is
perhaps nearly the same, as are also the blood diseases already stated to
follow next in the scale.
   Upon the whole, the exanthematous crasis has the greatest affinity to
the typhous.  Only the  blood is still more fluid, whilst the violet tint
present in intense typhus is wanting.  The blood verges more upon pur-
ple^—upon cherry-red.
   The dead body manifests a certain degree of turgor.   There is a lack
of that tenseness of the muscles, and of the common integument, as also of
the dingy-gray coloration of the latter.  The skin is  indeed rather white,
although with extensive,  very saturated death-patches.  The serous mem-
branes very often exhibit  a viscid, ropy, colorless covering.  Local  hy-
peraemiae, partly of hypostatic nature, and imbibition of the textures with
blood-pigment, are observable.
   Along  with these differential points, and apart from the resemblance
in the anatomical characters,.of the  blood, special analogies come forth
between the typhous and the exanthematous crasis.  Such as:
   (a.)  The relation of the exanthematous crasis  to  the  mucous mem-
branes, and also to  the lymphatic glands.  It  is expressed in the well-
known catarrhal,  erythematous, and  other  affections of the respiratory
and gastro-enteric tracts of  mucous membrane ;—in the well-known en-
largements of peripherous lymphatic glands accompanying the course of
the exanthemata.   What  is, however, particularly characteristic, is the
development of the follicle apparatus of the ileum and of the mesenteric
glands in scarlatina, and in the entire series of analogous blood diseases.
   (b.) The identical conversions of the crasis observed in typhus.  The
most frequent are the conversion to the croupous crasis, including  the
tuberculo-croupous,  with corresponding local  products,  and the often
early degeneration to putrid decomposition.
   Among the sequelae  there is one proper to typhus, and also a very
frequent consequence of scarlatina,—namely, protracted albuminuria.
   Another consequence of the exanthematous processes, is intense inspis-
sation of the blood, with marked hyperaemiae and stases.
   As far  as its crasial source is concerned, variola does not seem to con-
stitute an exception.   It is, however, essentially obnoxious  to a speedy
transition into the croupous-crasis and into pyaemia,  the latter often out-
running its normal term.   In  common with the exanthematous crasis
generally, it is liable to  degenerate early into putrid decomposition,
which, anticipating the croupous and the pyaemic phases, precludes the
formation of any products due to these modifications of  the exanthema,
and causes the pocks to  degenerate into the so-called putrid.
   Amongst the diseases  following closely in the wake of themore promi-
nent exanthemata, the under-mentioned are peculiarly deserving of notice,
namely:
   A large proportion of puerperal fevers—especially when bearing  an 
294
EXANTHEMATOUS  CRASIS.
epidemic impress.   The characters presented by the dead body, and the
anatomical relations of the blood, answer to the exanthematous crasis ;
to which may be added, the  presence of the exudatory processes above
specified upon the uterine mucous membrane, the character of exudates
detected upon the  serous membranes, especially the  peritoneum,  and
finally, the frequency  of concurrent exanthema, in the  shape of ery-
thema and of scarlatina.   These puerperal processes are marked by their
tendency either to become converted into the croupous  crasis, or else to
degenerate into putrid decomposition.  Nor is acute  softening of the
stomach a rare coincident phenomenon.
   A crasis appertaining to this class often becomes localized, as one of
the exudatory processes adverted to, uponthe intestinal mucous membrane,
as in many instances of acute diarrhoea and of dysentery.  These often
prove fatal through paralysis of the intestine—through exhaustion.  A
very remarkable and  momentous phenomena, however,  is  a resulting
thickening of the blood to a dark red liquid, of a tarry appearance, and
of the consistency of treacle.  It proves  fatal under the symptoms of
anaemia in vital organs [lungs, brain], of rigor [tonic spasm] of muscular
organs, or else through local hyperaemiae  [for example  of  the  brain].
Eruptive phenomena in the progress  of the dysenteries  are not at all
uncommon.
   Conversions of the  crasis  to the croupous and to  protracted pyaemia
are frequent.
   Next in the series is the cholera-process.  It is a more  or less rapidly
developed  hypinosis,  with the  characters of  the exanthematous.  Its
localization extends over the entire intestinal tract as an exhausting exu-
datory process, multifarious in its products, and either proving rapidly
fatal under acute inspissation of the blood and the aforesaid  contingent
phenomena, or else passing over into a so-called stage of reaction.
   In the former case, the dead subject presents a dingy,  blue-gray colora-
tion of the common integument—a puckered  state of the latter and of
the areolar tissue, with herb-like  dryness and rigidity, and with dark
coloration of the muscles.  The blood, if we except certain stases in dif-
ferent ranges  of the vascular  system, especially in the bloodvessels of
the membranes of the brain, is  found  acccumulated in the  vascular
trunks, and in the  heart,  as a dark tar-like mass, without fibrin-coagu-
lum.  The lungs are for the  most part dry, inflated, of a deep red ; the
serous membranes—more especially the peritoneum—moistened with an
abundant viscid coating.   The  intestinal canal is the  seat of an exten-
sive, and equally rapid and  intense process of exudation, and presents
the general lineaments of paralysis.  Surcharged as  it  is with fluid, it
is nevertheless collapsed,  soft, and flabby-membraned, pallid, rarely  pre-
senting  any intussusception.   It contains, in varied measure, a  serous
fluid, rendered turbid, whey-  or  rice-water-like,  whitish or yellowish-
white, by the debris of epithelium and minute particles of protein  sub-
stances, or else slightly reddened  by the intermingling of blood.   The
mucous membrane is denuded of its epithelium, and bare; or the coagu-
lable portion of the exudation may adhere to it in the  shape of  a loose
 bran-like covering,  or of membrane-like formations.   Its texture  is
 bloated, and is  for the most part readily scraped  off, as a reddish-white 
drunkard's dyscrasis.
295
pulp;  its follicles,  especially at  the ileum,  distended by exudate  to
the bigness of millet or hemp-seeds.  The spleen  is shrivelled, the uri-
nary bladder empty.  In the ganglia of the sympathetic we detect little
hemorrhagic spots,  as big as a poppy or millet-seed.
  In the so-called stage of reaction, the crasis reverts  to the normal,  or
else the hypinosis changes under expansion of the blood into a typhoid
disease.  The latter is remarkable for a secondary localization upon the
mucous membrane of  the  intestines, in the shape  of repeated processes
of exudation, and also for exanthematous  processes simulating measles,
scarlatina,  pemphigus  or  erysipelas, upon the   common  integument.
During the thus protracted course of this hypinosis, it is very usual for
a fibrino croupous crasis to develope itself,  and for the mucous membrane
of the intestine, of the stomach, of the oesophagus, of the trachea,  to
display croupous exudation,—the lungs, croupous pneumonia.
  This hypinosis is moreover convertible to pyaemia, to acute  softening,
and also liable to putrid decomposition.

             (d.) hypinosis in diseases  of the nerves.

   The similarity of the crasis in this class  of diseases with the typhous
and exanthematous erases is very striking.  It even  partakes, in com-
mon with these,  of a proneness to  localize itself upon  the intestinal
mucous membrane in  the follicular apparatus of the ileum,—in a tumes-
cence [product-formation] of the Peyerian and solitary gland capsules.
  To this category belong diseases with obvious anatomical disturbance
in the nervous centres, and again diseases in which such disturbance  is
either wanting or subordinate  and  consecutive.   Such are meningitis,
acute  hydrocephalus, apoplexy, and the  like; and  again, acute tonic
spasm and  convulsions, tetanus,  trismus,  puerperal  convulsions, pro-
tracted epileptic convulsions, &c.; lastly, hydrophobia.
  In the latter diseases, more especially, in which  up to the present day,
no  anatomical disturbance  is  demonstrable, the  question  arises as  to
whether the nervous system be  substantially impaired  at  all,—whether
the anomaly in the crasis be not the primary cause of the nervous phe-
nomena.
  It appears to us that, although the most accurate examination may be
inadequate to prove any  palpable  anatomical  disturbance, a primitive
affection of the nervous  system must nevertheless  exist, and  be that
which determines the  [secondary] anomaly of the crasis.
  This crasis  not unfrequently degenerates into putrid decomposition.
It often becomes converted into pyaemia, and not unfrequently issues  in
acute softening.
  In  fine,  those rapidly destructive liquefactions  of the blood  may be
here classified, which, under the name of  asphyxia furnish  forth the
majority of  instances of sudden death, commonly through hyperaemia
of the lungs with acutely developed pulmonary oedema.

                 (e.) the drunkard's dyscrasis.

  That dyscrasial  condition induced by the abuse of alcoholic drinks,
and especially of gin, occurs under two forms, differing  in the course 
296
drunkard's  dyscrasis.
 which they run—in other words, there is a chronic and also  an  acute
 drunkard's dyscrasis.
   The first, namely, the chronic crasis, manifests itself as plethora, with
 a remarkably dark coloration, a thickness and a simultaneous  fattiness
 of the blood.  This  occasions, and at the same time accounts for, the
 condition in which we find the solids.
   The pigmented appearance of the skin, the excessive, and, at the same
 time, anomalous  fat-formation,  and blennorrhoeae,  are all characteristic
 of the crasis.  The corpses of inveterate  dram-drinkers present very
 marked  appearances.   The  skin is tinged of a dingy brown, and this is
 coupled with the  fact,  that not unfrequently parts naturally rich in pig-
 ment—the scrotum, for example, become deprived  of it.   At the same
 time the skin is of a soft, unctuous  feel, like that of the negro, and its
 epidermis la}Ter is thin.  Subjacent to the skin, and also in the mesen-
 tery and the omenta is deposited fat, in an excess if not  absolute, at
 least relative to the state in which we find the muscles, and possessing a
 peculiar  character not unlike that of mutton suet.   Together with this,
 the muscle-flesh  appears to  have lost in volume, and to  have become
 pallid.   The fat-formation steals into  the muscles in the shape of fatty
 conversion.   The  liver has undergone fatty degeneration.   Even in the
 bones the fat formation  has  gained  ground at the expense of the bony
 texture.
  All  the mucous membranes, but especially the bronchial and intesti-
 nal,  are  affected  with chronic thickening  and with  blennorrhoea, the
 chronic gastric catarrh [gastric irritation] being particularly marked. A
 similar state of hypertrophy presents itself in the  habitually congested
 cerebral membranes, in the form  of dulness, thickening, chronic oedema.
  The brain  is affected Avith an atrophy like that met with  in the aged,
with or without considerable  dilatation of, and serous  effusion into, the
ventricles.
  The blood  appears dark-colored, grumous, defibrinated, viscid-unctuous
to the  touch, often intermingled with fat in large quantity,  as fat-drops.
In rare instances the disease occasions a chyle-like opacity of the plasma
—milky  blood.
  The chronic drunkard's crasis often undergoes conversion  to fibrin-
erases  of various kinds.  Amongst these are inflammations with fibrin-
products, even tubercle.  Pneumonia  is a very frequent and  very fatal
disease with  drunkards—pneumonia running an acute course, and pos-
sessing an eminently croupous  character.  Chronic  hepatitis, determin-
ing organizable  products, and  leading eventually  to  liver-cirrhosis
[granulation], is a very common termination.
  In  drunkards tuberculosis runs an eminently chronic course.  The
deposition of tubercle is for the most  part inconsiderable ;  the granula-
tions are  generally of a dingy, or a greenish-gray, and do not soften as
such.   The yellow tubercle and resulting phthisis are more rare.
  The natural issue of the drunkard's crasis is in eventual hydraemia__
in dropsy—which  assumes a local form, especially that of ascites the
more   speedily,  the  earlier  heart-disease  or  liver-cirrhosis   becomes
established.
  The acute  crasis has a marked resemblance with the exanthematous 
acute tubercle-crasis.
297
 and with the crasis in nervous affections.   The liquefaction with discolo-
 ration  of the  blood and, as a consequence  thereof, the tendency  to
 transudation of blood-serum, are for the most part more developed. The
 fat is wont to separate from the blood in the form of largish drops.
   The  corpses present extensive, very saturated death-patches ;  evanes-
 cent rigor of  the dark red muscles; congestion of the cerebral mem-
 branes, and still more of the lungs, especially as hypostasis; scattered
 patches of stasis in  the intestinal mucous membrane, &c.   The paren-
 chymata are lax; those affected with hyperaemia, imbibed with a colored
 blood-serum.   In the cavities of the serous membranes—more especially
 of the pleura—are dingy-red, serous  [spurious hemorrhagic] effusions.
 The corpses emit a peculiar sweetish smell, and pass rapidly into  decom-
 position under  gas development.
   The inflammatory stases  developed  during the progress of this crasis
 are, for the most part, hypostatic pneumoniae.   They determine a pro-
 duct dark-colored from adherent haematin, lax,  soft, incompetent  to
 hepatize the lung-texture.
   This crasis never becomes developed in aged persons broken down by
 repeated attacks of delirium tremens, but invariably in drunkards in the
 early  years of manhood, who are endowed  with a powerful muscular
 system.  It runs a very rapid course, leading,  in a very few  days to de-
 composition.
   We are aware of  no instance of this crasis passing into the fibrinous
 crasis, or into pyaemia.  On the other hand,  it often becomes exalted
 into  decomposition, and  not  unfrequently issues  in  softening  of  the
 stomach.
   It is not improbable that this crasis is, in the majority of cases, due
 to injury sustained by the brain during a violent or protracted fit of in-
 toxication, and  that it ought  rather to have  found a place  in the pre-
 ceding chapter.  It is not in aged  drunkards,  with  an atrophied  brain,
 that it occurs, but in younger individuals with a brain of  normal de-
 velopment, keenly sentient of congestion, and of an alcoholized condition
 of the blood.

              (/.) the crasis of acute tuberculosis.

   This  crasis has the greatest resemblance with the exanthematous, and
 the disease  assimilates so  closely in its  manifestations during  life  to
 typhus [intestinal typhus], as only to be  distinguishable from the latter
 by the absence of abdominal symptoms, the more marked phenomena
 pointing to exudation in the membranes of  the brain and upon the
 linings of its ventricles.
  The product  of this crasis is a tubercle  presenting many peculiarities.
 It is a  scattered corpuscle, mostly smaller than  a millet-grain, and no
 bigger than a poppy-seed, or even a pin's point.   It  is now of  glassy
 transparency, vesicle-like;  now grayish, semi-opaque, soft, gluey;—
 then, again, verging  upon  whitish, or  yellowish-white, and  opaque.
 With it there always exudes a grayish, more or less albumen-sated, semi-
gelatinous serosity, infiltrating—drenching—the involved textures. The
deposition of these products always  affects an organ in wide extension. 
298
CANCER-DYSCRASIS.
Generally speaking, indeed, several organs are implicated at once, more
especially the lungs, the cerebral  pia mater, the spleen, the liver, and
the serous membranes.   The tubercle is always deposited in great num-
bers, and is equably disseminated throughout an organ, as the examina-
tion of an involved lung  or spleen  shows at a glance.
  The tubercle  is sometimes primitive, but  more commonly successive
to a pre-existent fibrin-tuberculosis.  Looking at the physical properties
of this  tubercle, apart from any  chemical  analysis,  and connecting it
with the crasis of  which it  is the product,  we are constrained to set it
down  as an albuminous formation.
  With reference to the  crasis itself, which, as we have  said, is marked
by a hypinosis closely resembling the exanthematous, it may be asked
[and the question  is  replete with interest]:  is  acute tuberculosis primi-
tive, or is it but  a consecutive state of defibrination of the blood, brought
about through the antecedent out-throwing of a large proportion of fibrin,
in the shape of tubercle ?
  Or  is  it one  of the so common tuberculoses connected with  hydro-
cephalic effusion of the internal membranes of the brain, that  is, con-
secutive hypinosis, determined by  disease  of the brain ?
  Seeing that acute tuberculosis occurs under conditions  which preclude
either of the contingencies here referred to, not a dOubt can remain as
to its protopathic character.
  A further  question is: how, in  this hypinotic crasis,  is  the tubercle
brought about ?
  [For a reply to  this question the reader is, to avoid entire repetition,
referred  to the section  on  " Albuminous  Tubercle,"  in  the  present
volume, p.  246.]
  Acute tuberculosis probably always proves fatal.
  Occasionally, owing to very extensive deposition, the  crasis approxi-
mates to hydraemia.   It  does not  pass into putrid decomposition, nor is
it converted into pyaemia.  On the other hand, acute softening of the
stomach is a frequent follower in its train.
  The corpses present, generally  speaking, the same phenomena as in
typhus; namely, pale skin, extensive, deep-colored patches of lividity,
tense, dark-colored muscles, hypostatic hyperaemiae. The parenchymata,
especially those which have been the seat of tubercle-deposition, are tur-
gescent, and drenched with sero-albuminous fluid.

                       (g.) CANCER-DYSCRASIS.

  A crasis the existence of  which  is shown from  the  exclusive  relation
stated, in the general section on Tubercle, to exist between cancer and
tuberculosis.
   To  demonstrate a cancer-dyscrasis from  anatomico-clinical data is
one of the most difficult tasks.  The basis of such  a demonstration is
the immediate character of the  blood, the  peculiarity  of  the cancer-
formation,  and of  other  exudates brought about in various ways under
the crasial influence ; and, lastly,  their relation to new growths  proper
to other known erases.
   The blood itself affords evidence  of a  hypinosis.   This is however 
CANCER-DYSCRASIS.
299
not of itself alone cognizable as  a specific cancer hypinosis.  To prove
this  the presence of cancer-formations  is indispensable, and even these
must needs  give evidence of their general import, either by redundant
growth or by multiplication ;  in short, they must in some way betoken a
direct  relation with a dyscrasial state of the blood.
  Further evidence respecting albuminosis is afforded  by the presence
of albuminuria, of lardaceous infiltration of  the liver,  spleen, kidneys;
more particularly, however, by inflammatory products, as albuminous,
white,  emulsion-like, in part  slowly solidifying, ulcerating, or cancer-
forming exudates ; lastly, by the exclusion of concurrent fibrinous pro-
ducts,  and especially of fibrinous tubercle.
  The abundant fat-formation not unfrequently co-existent with carci-
noma may be cited in proof of the participation of fat in the cancerous
albumen-crasis.   This is exemplified in osteo-porosis from the excessive
formation of bone-medulla; in the fatty contents of the cancers, and of
albumino-cancerous exudates ; in the deposition of fat as  cholesteatoma,
as gall-stone, &c.
   The cancerous hypinosis manifests its impress in various grades.  It is
intense in cases of voluminous, exuberant cancers ; in very widely-spread
cancer-production, whether spontaneous, or called forth by the extirpa-
tion of bulky carcinomata; but most especially in cancer of acute growth,
and of the  medullary character.  The blood often contains, in  nucleus-
and cell-formations, the  elements of  cancer.  In  chronic vegetation,
and especially in pure fibrin-cancer, the hypinosis is often less marked ;
whilst, in cancer of local import, it may be altogether wanting.
   The cancer-crasis is either primitive or  consecutive,  that is, deve-
loped  out of a  hitherto local cancer.  It is either  acute or [more often]
chronic.
   The acute crasis  is  in rare  instances protopathic;  more commonly,
however, it  is developed out of the chronic, especially after the extirpa-
tion of extensive cancers.   It localizes  now in the more vigorous growth
of a cancer already in existence, now in the simultaneous or in the suc-
cessive, hasty production of new cancers [of the medullary form] in the
most various organs  and textures, conducing thus to rapid  wasting of
the blood, and  proving fatal within a term  not exceeding that of the
most acute erases known.
   In its chronic development it  terminates in marasm of the blood, in
hydraemia, in anaemia, the more rapidly, in proportion as the seat of the
cancer [in  the stomach,  for example] is calculated to interfere with
the work  of nutrition, or in  proportion to the  loss of blood  by hemor-
rhage.
   Under such conditions the cancer-crasis may wear itself  out, and the
cancer-tumors  participate in the waste and decline  of  the  entire  or-
ganism.  This explains the circumstance that in a venosity verging upon
hydraemia and depending upon central organic impediments to the circu-
lation, cancers  hardly ever  occur.                                   .
  The cancerous hypinosis  is, as we have  already pointed out, absent in
local carcinoma.   The  concurrent crasis may be the  normal,  or  some
anomalous one  not  of a cancerous nature.
  The fibrin-erases, however, accompanying, or at least coincident with 
800
CANCER-DYSCRASIS.
cancer, are of great interest, not alone, as running counter to our theory
of the nature of cancer, but more particularly because, if correctly seen
and  comprehended, they  afford the  best  means  of demonstrating the
specific character of the cancer-crasis.
   1.  In the Arst place, it is conceivable that Abrin-crases  may become
developed along with  local cancer.   They  are, no doubt, sometimes pri-
mitive, localizing  themselves in the local cancers, as inflammations ;
sometimes  consecutive, that is, brought about  in  the cancer itself by
mechanical  or  medicamental  influences.   The Abrin-crasis concurrent
with  local cancer may even be of a  tuberculous character, and lead to
tuberculous  deposition.
   2.  A Abrin-crasis  may, however, become developed even conjointly
with  cancer of  general import, that is, out of cancerous  hypinosis  or
albuminosis.  The cancer-crasis is co-ordinate with other, similar [hypi-
notic] erases, out of which  we have seen that Abrin-crases, more  espe-
cially those of a croupous  character, may emerge.   They  may arise
either directly out of  the hypinosis, as a conversion of the latter, or else
through the instrumentality of an  inflammation with cancero-dyscrasial
blood, in which a development of fibrin takes place.
   The cancerous fibrinosis, in whichever  way  brought about, localizes
itself in  inflammations of  the  serous  tunics,  in  carcinomato-fibrinous
hepatizations of the lung,  as also in spontaneous coagulations within the
vascular system, including the capillaries  [cancero-capillary phlebitis].
Both these and the exudates  are distinguished for their opacity, their
whiteness [changed by contained blood-globules to grayish-red or red],
their soft, lax  consistency, their albuminous  contents, their medullary
characters.  They are  sometimes  fundamental to cancer-formation,—
the most acute and most extensive cancer-formation,—both intravascular
and  extravascular.   At other  times they liquefy to a white, cream-like,
lardo-glutinous ichor.  They contain the rudimental elements of cancer
in redundant quantity.
   In the description just given, a peculiar constitution of the fibrin under
the conditions both of its organizability and of its liquefying tendency is
undeniable.   It is essentially  proper to cancer, and affords incontestable
proof of the speciAc constitution of the albumen in  cancerous hypinosis.
Where a Abrin crasis developes itself, whether in the totality of the  blood
or in a local process  [inflammation], this peculiarity  of constitution  is,
without doubt, transferred from the  albumen  to  the fibrin.   A proof,
this, how intimately it clings  to both substances;  a proof of the exist-
ence of a cancerous fibrin-crasis ;  and at the same time an indication of
the sense in which the balance between  cancer-crasis and fibrin-crasis is
to be understood.
   This cancerous fibrinosis, in fine, is the parent of a peculiar tubercle,
of cancero-fibrinous character, which corresponds well with cancer-crasis,
and more particularly with such of  its highest  grades as  have attained
the point of fibrinosis; a  tubercle, moreover, which, as we have seen  at
page  237, answers in  all respects to cancerous fibrin. 
ANEMIA.
301
                      3. hydremia;  anemia.

                 (a.)  The Serous Crasis ; Hydraemia.

   Fibrin, albumen, blood-globules, are here all diminished in quantity;
the amount of ivater increased.   The blood is attenuate, watery, pale in
various degrees to the point of water in which flesh  has been  steeped,
wanting in tenacity.  It contains very inconsiderable, loose, soft, curd-
like coagula holding much serum, which, by pressure  is reducible to  a
few drops.
   The water transudes through the parietes of the vessels in dependent
parts, or in such as, owing to mechanical influences, are particularly ob-
noxious to hyperaemia, drenches the textures in the form  of oedema,
especially the areolar tissue, even to the medullary system of the bones,
and forms, in serous cavities,  dropsical effusion.   It may transude pure,
or may contain a certain proportion of albumen and even of fibrin, which
latter [as so called spurious fibrin] determines in the textures a soft curd-
like coagulation of the dropsical fluid;  and in the cavities separates in
the shape of  soft curd-like flakes.  Inflammatory products are marked
by the large amount of  their serous  contents, and by their poverty in
plastic materials.
   The dropsical crasis occasions defective nutrition, with  pallor of the
textures, relaxation of the contractile fibre;  in the dead body,  the deve-
lopment of pale death-patches.
   It becomes mortal through insufficiency of nutritive matter in the blood;
but for the most part proves fatal at an earlier stage through local oedema
of the textures, and dropsy of the great serous cavities.
   Not every dropsy is, however, the result of hydraemia.  We allude to
those local and general dropsies  brought about by mechanical impedi-
ments to the circulation in the veins, in  the heart and great vascular
trunks,  and in the lungs.
   The serous crasis is sometimes idiopathic,  produced by climatic  rela-
tions, by peculiar alimentation, by anomalies in  the chylopoietic system,
by repeated, exhausting  hemorrhages, &c.  Nay,  it may be even conge-
nital and constitutional.   The condition of the blood  in haemorrhophilis,
seems to be essentially that of hydraemia.  In most instances, however,
it is secondary,  developed as a sequela to some other crasis, for example,
as a consequence of the habitual outpouring of albumen, the separation
of fibrin in large aneurisms, the deposition of fibrin and ^ albumen in in-
flammation-products, in tubercle, in cancer, in albuminuria.  Or else it
ensues upon a specific, chronic or acute blood-consuming dyscrasis, upon
metallic poisoning,  typhus, and the like.

                            (b.)  Ancemia.

  Deficiency of blood, in various degrees, by no means offers any dis-
tinctive  crasial characters, if we except the  hydraemia—the excess  of
water__into which  every persistent anaemia eventually resolves  itself.
The anaemia or oligaemia, is brought about in various ways; for, what- 
302
SEPTIC CRASIS.
ever be the crasial constitution of the blood, it is liable to an accidental
reduction of its mass.
  It is, most frequently of all, a consequence of loss of blood through the
various kinds of hemorrhage ; next to that, of  insufficient alimentation,
of excessive bodily and mental labor, and of the continuous loss of fluids;
of the  inordinate production and increase of new growths, even of redun-
dant fat formation, especially in  children ; of  disease of the nerve-cen-
tres, especially of the brain, such as hypertrophy, heterologous growths,
concussion.   Or it is the sequel and issue  of intense typhus-crasis ;  of
chronic metallic poisoning, &c.   It  accompanies  all general atrophy,
both in old age and in earlier life.
  Moreover,  oligaemia is not unfrequently a  congenital, constitutional
state, and affects by preference the female sex.   It involves a correspond-
ing defective development of the calibre of the arteries,  with smallness
of the  heart,  and with a generally stunted growth of the animal frame.
The female sexual organs seem more especially crippled in their develop-
ment.   It was stated that blood of every admixture  may suffer an acci-
dental reduction of its  mass through hemorrhage,  without  becoming
alienated from its original crasis.   In like manner, anaemia is probably
never  purely such; that is to say, never brought about  by the  equable
reduction of each of its constituent parts, but at the same time invariably
a dyscrasial  condition.   How  inextinguishably the  dyscrasis clings  to
croupous blood, even after the most copious bloodlettings; how, in the
highest grades of blood-deficiency, the tuberculous constitution attaches
to the smallest remnant of fibrin, we have  already seen.
  The most striking  picture of  anaemia  is furnished  in the dead bodies
of persons who have  died of hemorrhage.   Collapse  and pallor  are the
outward signs reflected from within.  The deathmarks, if there be  any,
are very pale.  There is considerable rigidity of muscle, firmly contracted
heart,  presenting the aspect of concentrical hypertrophy, bloodlessness,
both of the endocardial cavities and of the  vascular trunks, especially the
arteries.  In corpulent individuals with a white skin,  the common integu-
ment is of a  waxy paleness.   In profound dyscrasial anaemiae [the con-
sequence of typhous or metallic poison] the dead subject retains, together
with the pallor, the characteristic cachectic hue.


4. DECOMPOSITION.   PUTRID, SEPTIC CRASIS.    SEPSIS OF THE BLOOD.

  We have repeatedly had to refer to a decomposition, a putrid decom-
position [sepsis] of the blood, as a consecutive crasis resulting from the
degeneration of another crasis.
  The conditions we are  here concerned  with vary, as  the  anatomical
results show, with the causal influences at work, as also  with the differ-
ences due to pre-existent erases.
  Generally speaking, these conditions manifest themselves in decompo-
sition, in dissolution, in necrosis, in a death of the blood, and they  com-
prise the commonly called scorbutic, the chronic and acute, putrid states
of the circulating fluid.  A very broad line of demarcation,'coming under
anatomical  notice, and which separates  the states referred  to into two 
SEPTIC CRASIS.
303
series is that, in the one case, the sepsis has the character of a fibrin-cra-
sis, in the other, that of a deficiency of fibrin.  Accordingly, if we except
the two common features of thinness and discoloration of the blood gene-
rally, a comprehensive  view of all these states is not feasible.
   Regarded from a clinico-anatomical point of view, the various condi-
tions of septic crasis occur in the following forms :
   1.  The purest and most simple forms of sepsis are :
   (a.) A decomposition or necrosis of the blood brought about without
any cognizable agent of fermentation is that due to a shattered state of
the nervous system and of its function, proving fatal with lesser or greater
rapidity [sometimes in a very few moments], according to  the measure
and amount of the shock.  To this category are to be referred  decompo-
sitions of the blood consequent upon concussion and severe injuries, con-
cussion from a fall, from the extensive laceration or the crushing of soft
parts or of bones; upon extensive amputations ; upon the continuous, ex-
hausting activity of the muscles  in violent convulsions, of whatever kind ;
upon electrical shocks received [lightning] ;  upon mental emotion of  an
overwhelming nature.   A very  striking exemplification offers in the de-
composition of the blood not unfrequently called forth by a difficult and
exhausting act of parturition involving palsy of the womb; cases which
often prove fatal after a very few days, or even hours.
   In all these cases the blood is found attenuate, in color comparable to
a raspberry jelly,  or of a  dingy red, facile  of imbibition, expanded in
volume, often engaged in gas-development, frothy.   The blood-corpuscles
are swollen up, the serum being deeply reddened by haematin withdrawn
from them.    Coagula, if present at  all, appear  as very inconsiderable,
soft, curd-like fibrin-clots.   The frequent large  peritoneal exudates, oc-
curring more especially in  puerperal  decomposition, are dingy-red,  dull,
thin, sometimes  rather viscid fluids.   The  dead bodies present  but little
and evanescent  rigor, much inflation, extensive and deep lividity.  The
internal organs, the heart's muscle, the parenchymata are lax, flabby;
the bloodvessel coats and the endocardium,  discolored from imbibition;
those parenchymata whose bloodvessels  are  most injected  are  more or
less discolored by imbibed serum.   The blood is always largely accumu-
lated in particular sections of the vascular system, be it in the nerve-
centres, in extensive patches of the mucous membrane  of the stomach
and intestines, in the sexual organs of women, but most particularly in
the lungs, as hypostasis.
   The corpses pass into putridity, under the phenomena of  gas-develop-
ment in the bloodvessels, emphysema in the  textures, copious transuda-
tion of a dirty-red serum into the serous cavities, and  spontaneous vesi-
cation of the epidermis.
   (b.) Those decompositions consequent upon faulty diet [true scurvy],
the reception of corrupt matter,  of miasmata, of animal poisons into  the
blood, &c.
   The dead bodies present, generally, the  characters already specified.
Owing,  however, to the  expansion of the  decomposed blood,  transuda-
tions of blood-dyed serum in the shape of ecchymoses  of the  textures,
and actual hemorrhages, are especially  apt to take place.
   2. A second form of decomposition is  that so frequently attendant 
304
SEPTIC CRASIS.
upon hypinotic crasis, and which we have before described as an exalta-
tion  or degeneration of the  typhous,  of  the exanthematous, of  the
cholera-, of the drunkard's dyscrasis.   Its  relation to the fundamental
crasis may be regarded as a varying one.   Here we may observe :
  (a.)  The putrid decomposition, impelled  by a special external agent,
becomes complicated with the hypinotic crasis, a septic venom  being
superadded to the  exanthematous contagion or  the typhous miasma.
There being essential putrid decompositions independent of those other
agents,  and the symptoms of septic poisoning often occurring very early
during the progress of the other diseases cited, such a relation is placed
beyond all doubt.
  (b.)  The sepsis is a dissolution  of the blood in the hypinotic crasis,
resulting  from the  profound injury  inflicted  by this crasis upon  the
nervous system.  This implies, either a very intense hypinosis [a very
intense  miasma or contagion], or  else a  very susceptible nervous system.
Thus it may happen that typhus and  exanthemata pass into putrid  de-
composition even in epidemics by no means  of a malignant type.
  (c.)  Or, in fine, it is possible that a hypinosis occasioned by miasma or
contagion, may, of itself and without the mediation of the nervous system,
become degraded into a putrid crasis, simply through putrid conversion
of the received miasma.  It is in this sense, more particularly, that  the
exaltation or the degeneration of a primitive crasis to the putrid is to be
understood.   The blood and the corpse present the same appearances as
in the first form; the marks of decomposition and  putrefaction being,
however,  if possible, still more clearly defined.  The different hyperaemiae
are also more distinctly  expressed—such hyperaemiae as  are proper to
the original hypinoses.   They occupy, frequently in the shape of ecchy-
moses and hemorrhage of the  textures into which they have degenerated,
those organs   or  parts of  organs in which the original  hypinosis  had
localized itself;  for  example,  the intestinal  mucous membrane, in putrid
typhus; the  common integument and the great tract of the respiratory
and intestinal mucous membranes, in  exanthematous processes.   Not
unfrequently, the septic crasis of this form localizes itself in deep-colored,
absolute stases, especially in peripherous organs, where, without a trace
of organizable products,  they  terminate in necrosis of the blood and of
the textures, with conversion thereof to a  soft, humid, dingy, deep-red
mass,—a gangrene-slough.
  A stringent differential diagnosis from the blood itself is, however, not
feasible in all the cases of the first and  second forms.   It is only to be
deduced from the anatomical  disturbance of the solids generally, and, in
cases of the second form, in particular,  from the products of the original
hypinosis,—typhus, exanthema, &c.   For instance, where the intestinal
mucous membrane reveals  the marks and residua  of  a typhous process,
the  sepsis will  have arisen  out  of the typhus-crasis.   Where obvious
anatomical disturbance does not exist,—for example, in the case of  con-
vulsions,—or where  the  products of  a hypinosis,  owing  to  the early
supervention  of sepsis, are inconsiderable or only faintly  indicated,  and
where, lastly, clinical records are wanting, the diagnosis must needs rest
upon probabilities alone.
   3. A third form,  differing from the two former, is  that of a sepsis of 
               ANOMALOUS  BLOOD-CORPUSCLES.            305

the blood resulting from the fibrin-crasis, especially the aphthous, and
from pyaemia. It manifests itself, in the first instance, as a putrid decom-
position, as a necrosis of the fibrin, which forthwith possesses itself of
the entire blood-mass.  It has  been already discussed under croupous
crasis y, and under pyaemia, as  aphthous and purulent sepsis.
        INDEPENDENT ANOMALIES OF THE BLOOD-CORPUSCLES.

  An anomalous relation of  the blood-corpuscles, founded in dyscrasial
conditions of the plasma, occurs under several forms, some of which have
been already adverted to, especially those of turgescence, pallor, or pre-
ternaturally deep coloration ; of augmented or diminished adhesiveness;
and the like.  As an independent anomaly, their diminished number in
genuine chlorosis is alone recognized.

   Other erases deserving of notice are :
   The hemorrhagic crasis [haemorrophilis], specified in the chapter on
" Hemorrhage."
   A crasis which determines the deposition or stratiform coagulation of
a protein substance upon the inner coat of bloodvessels cannot, in  our
opinion,  be pretermitted.  The little that we have to  advance upon this
subject, however, we  shall reserve for the chapter  on " Diseases of  the
Arteries," in vol. iii.
   The retention of urea in the blood occasions and sustains a  hypinotic
crasis;  and in certain cases, as in acute nephritis and acute albuminuria,
tends to induce  a complete decomposition of the  blood.
  A biliary dyscrasis is produced in two  different ways:  first, through
diseases of the liver and gall-ducts,—inflammation of  the  liver, obstruc-
tion of the latter through retention in the blood  of the  elements of  the
bile;  and secondly, through endosmosis of bile (resorption) into the blood-
vessels.
  The croupous-crasis and pyaemia often give rise, without demonstrable
liver affection, to the elements of  the  bile being  set  at large in  the
blood.
  In fine, there is a spontaneous  biliary  cra"Sis  which,  running a very
acute course under the most intense typhoid symptoms,  and under colli-
quation of the parenchyma of the liver,  proves fatal through decomposi-
tion of the blood. So intense and violent is the  conversion to bile in the
blood, that even in the portal circulation,  previous  to its  entrance into
the liver, the blood has the look of blood impaired  by artificial contact
with bile. It is a dingy-brown or yellow-red, tenacious,  ichorous-looking
fluid intermingled with whitish fat-streaks  and jelly-like  particles of
fibrin.   The  bile secreted in the liver is so saturated,  and at the same
time so excessive in quantity, as to utterly dissolve the parenchyma of
  vol. i.                            20 
306            ANOMALOUS BLOOD-CORPUSCLES.

that organ,—that is, the hepatic cells—determining  a state  of collapse
and softening, which, in its appropriate place, we shall treat of as " Acute
Yellow Atrophy of the Liver."
   With regard to the constitution of the blood in gout, syphilis, chronic
skin eruptions, and many other diseases, although in each a  particular
anomaly does no doubt exist, it  has not as yet  been given to morbid
anatomy to substantiate its nature.
END  OF  VOL. I. 
       ROKITANSKY'S





PATHOLOGICAL ANATOMY.





         VOLUME II. 
 
A  MANUAL
OF
PATHOLOGICAL  ANATOMY.
             BY

  CARL  ROKITANSKY, M.D.,
CURATOR OF THE IMPERIAL PATHOLOGICAL MUSEUM, AND PROFESSOR AT THE
         UNIVERSITY OF VIENNA, ETC.
VOLUME II.
THE
ABDOMINAL VISCERA.
    TRANSLATED FROM THE GERMAN,

           BY

 EDWARD SIEVEKING, M.D.,
MEMBER OF THE COLLEGES OF PHYSICIANS OF LONDON AND HAMBURGH,
    PHYSICIAN TO THE NORTHERN DISPENSARY, ETC.
    PHILADELPHIA:
BLANCHARD & LEA.
        1855. 
C.  snERMAN  ft SON,  PRINTERS,
        19  St. James Street. 
EDITOR'S  PREFACE.
  The principal hospital of the Austrian capital, the largest in the
world, offers very extensive opportunities and unusual  facilities for
the cultivation of Pathological Anatomy.  Exclusive of the Lying-in
Hospital and the Lunatic Asylum, which occupy the same range of
buildings, the Kaiserlich-Koniglich-Allgemeine-Krankenhaus1 (Im-
perial Royal  General Hospital) contains  104 wards, capable of
receiving 2214 patients; 1247 beds being destined for males, and
967 for females.  We find that, in 1838,2 the number of patients
treated amounted to 20,545; of these, 2678 died, giving a mortality .
of 13-03 per cent., or one death in 7-6 cases.  As I am  not provided
with  tables of mortality for other years, I am unable to state the
annual average mortality in the hospital; but it does not appear, by
a comparison with the mortuary tables of the Viennese  Foundling
Hospital,  that  the year 1838 was marked by peculiar endemic or
epidemic  influences.   By the laws of the hospital,  post-mortem
examinations may be made of all who die within its walls.4  " To
examine all, or one half, would  be impossible;" but as " generally
from  four to six bodies are opened daily,"3 the extent of the field
presented for cadaveric research may easily be estimated.  For a
series of years, the Professorship  of  Pathological Anatomy has
been  held by Dr. Carl Rokitansky, and the  numbers  of medical
men of all nations who are attracted to Vienna by him, are the best

  1 Knolz, Darstellung der Humanitats und Heilanstalten Wiens, &c.  Wien, 1840, p. 169.
Wilde, Austria and its Institutions. Dublin, 1843, p. 124.
  2 Knolz, 1. c. p. 316.                  3 lb. 1. c. p. 56.
  * lb. 1. c. p. 190.                     5 Wilde. 1. c. p. 180. 
viii
PREFACE.
 evidence  of the manner in which  he has availed  himself of the
 opportunities at his disposal.  All who have been fortunate enough
 to attend the Professor's demonstrations, will be able to award him
 the praise of untiring industry, of acute judgment, and candid re-
 search.  Records of every case, taken down at the dictation of the
 Professor, are kept, and all interesting specimens  are preserved for
 the  Pathological Museum.   Rokitansky has embodied the  facts
 observed, and the conclusions deduced from them, in his " Hand-
 buch der Pathologischen Anatomie," published in Vienna during
 the  years 1841-1846.   The original forms  three large  octavo
 volumes; of which the third, containing the Pathological Anatomy
 of the Organs of Respiration and Nutrition, and of the TTro-Genital
 Tract, appeared first; the second, embracing the Morbid Anatomy
 of the remaining Organs and Systems of the Body,  followed; and
 the first, in which the Professor gives a philosophical survey of the
 entire Science of Morbid Anatomy, was published last. The Council
 of the Sydenham Society have  determined upon issuing the trans-
 lation in a similar sequence.  Owing to the acknowledged difficulty
 of the author's  style, it has  however been  thought advisable to
 divide the translation into four volumes, each of which is intrusted
 to a different editor.

  The  present  volume  contains the morbid anatomy of the
 Digestive  Apparatus and the Uro-Genital Viscera, which constitute
 the greater part of the third volume  of the original.  The succeed-
 ing two volumes will embrace the remaining portion of the third,
 and  the second volume of the original, and each  of these will be
 complete  in themselves, as far as regards the Special Pathology of
 the parts of which they treat.  The first volume, which contains the
 Principles or Theory of Morbid Anatomy, is a  scientific expose of
 the deductions and  inferences drawn by the author from the facts
 and illustrations given in the other sections of the work  and will
be the last to appear.  His views, as laid down in the volume of
 General Morbid Anatomy, are unintelligible to one who has not
previously studied the volumes of Special Pathology; this accounts
for the apparent inconsistency of publishing the  translation in the 
PREFACE.
ix
order adopted.  Were it not that the Council of the Society have
desired to adhere as much as could conveniently be done to the
original, the present volume might with perfect propriety have been
termed the first, and the succeeding volumes have been numbered
in the order of their publication.

  The fact of the Work having been selected for translation by the
Council of the Sydenham Society, is in  itself a proof that  it is
deserving of the high estimation in which it  has Jbeen held by all
pathologists acquainted with continental literature ; but it may not
be  superfluous to state that the value of the Professor's remarks is
enhanced by his being entirely unfettered by preconceived notions
or prejudiced views, as to the disease of the individual  brought  to
the dead-house for examination.   "Rokitansky," as  Mr. Wilde
correctly remarks, " differs  from  all other pathologists, in  not en-
gaging in the study or treatment of disease during life;  he is not a
practical physician, and seldom sees one of the many hundreds  of
cases,  whose bodies he dissects."  English  readers will probably
sometimes desire  more positive  statistical  data  than  the author
vouchsafes, and I cannot but express a hope that in the new edition
which Professor Rokitansky is preparing, he will in some  measure
repair an omission, which necessarily weakens his conclusions, and
deprives them  of that basis which the student looks for in patho-
logical anatomy, more even than in other departments of the natural
sciences.  I may, however, venture to  assert, that no one will read
his descriptions of post-mortem appearances without feeling  con-
vinced that they are drawings from nature.

  Of the difficulties connected with the translation, I will only say
that they are much increased by the figurative style of the author.
He constantly  uses terms in a sense peculiar to himself,  and his
total disregard for the ordinary rules of composition is an additional
and frequent source of obscurity.   It has been necessary to adopt a
few terms in the translation which, though new to the reader, have
been thought to convey most accurately the peculiar and idiomatic
expressions  of  Professor  Rokitansky;  this has not, however, been 
X
PREFACE.
done except where no word or phrase familiar to British pathologists
could be found exactly to convey the meaning of the author.

  In regard to the translation generally, I can only express a hope
that I have not perverted the sense of the original by the necessary
reconstruction of many passages, nor that, in adhering too closely
to the German, I have failed in making the English edition readable.

  In conclusion, I avail myself  of this opportunity to acknowledge
the honor conferred upon me by the request of the Council  of the
Sydenham Society to undertake the translation;  and I have great
pleasure in recording the obligations which I am under to Dr. J. R.
Bennett, the Secretary of the  Society, for the courtesy and assist-
ance  he has afforded me while the work was  going through the
press.
                                                        E. S.
    Brook Street, Grosvenor Square. 
CONTENTS  OF  VOLUME  II.
PART   I.
ABNORMITIES OF THE  DIGESTIVE APPARATUS.
                               CHAPTER I.

Abnormities of the Alimentary Tube,       .      .      .       .

        -Abnormities of the Mouth and Fauces,   ....
        Deviations in Form and Size,  ......
        Textural Diseases,       ......
        Adventitious Growths,  .      .
        Anomalies in the Secretions,      .....
        —Abnormities of the Pharynx and Oesophagus,
        Defect and Excess,       ......
        Acquired Abnormities of the Calibre, and the thickness of the Parietes,
        Anomalies of Position,   ......
        Solutions of Continuity,
        Textural Diseases, .
        Foreign Bodies,
        .—Abnormities of the Peritoneum,
        Defect and Excess of Formation,
        Anomalies in the Size and Form of the Peritoneal Sac
        Solutions of Continuity,
        Abnormities of the Tissues,
        Morbid Contents of the Peritoneal Cavity,
        ,—Abnormities of the Stomach,
        Original Arrest of Development,
        Deviations of Size,
        Deviations of Form,
        Deviations of Position,
        Solutions of Continuity,
        Diseases of the Tissues,
        Anomalous Contents of the Stomach,  .
        —Abnormities of the Intestinal Canal,
        Defective and Excessive Formation,
        Abnormities of Size,
        Deviations of Position, .
        Solutions of Continuity,
        Diseases of the Tissues,
        Anomalies of the Intestinal Contents,
Sect. I.—
21-
§2.
§3.
H-
Sect. II.-
11-
§2.
2 3.
§4.
2 5.
§6.
Sect.Ill
§1.
§2.
§3.
2 4.
2 5.
Sect. IV.
21.
2 2.
2 3.
2 4.
2 5.
IS.
2 7.
Sect. V.-
21-
2 2.
2 3.
2 4.
2 5.
2 6.
PAGE
 17

 17
 17
 18
 20
 20
 20
 20
 20
 21
 21
 22
 23
 23
 23
 24
 24
 24
 30
 30
 30
 30
 31
 32
 32
 32
 46
 47
 47
 48
 50
 57
 58
 92 
xu
CONTEXTS.
                                CHAPTER II.
                                                                          PAOE
Abnormities of the  Accessory Organs of the Alimentary Canal,      .     97

Sect. I.—Abnormities of the Liver,  .      .      .       .       .       .        97
     2 1.  Arrest and Excess of Development,   .....     97
     2 2.  On the Irregularities of Volume generally,  and on Hypertrophy and
           Atrophy in particular,       .      .      .       .      .       .97
     2 3.  Abnormities of Form,     .      .      .        .      .      .       101
     2 4.  Abnormities of Position,       .      .      .       .      .       .104
     2 5.  Changes of Consistency,   .      .      .       .      .      .       105
     2 6.  Diseases of the Tissues,       .      .      .       .       .       .105
Sect. II.—Abnormities of the Biliary Passages,    ....       123
     \ 1.  Excess and Defect of Formation,     .      .       .       .       .123
     § 2.  Irregularities of the Biliary Passages with reference to Calibre,   .       124
     2 3.  Anomalies in the Form and Disposition of the Biliary Passages,     .   126
     \ 4.  Solutions of Continuity,   .      .      .        .      .       .       126
     § 5.  Textural Diseases,     .       .      .      .       .       .       .126
     § 6.  Adventitious Products,     .      .      .        .      .       .       127
     2 7.  Anomalous Contents of the Biliary Passages, .       .       .       .128
Sect. III.—Abnormal  Conditions of the Spleen,   ....       130
     § 1.  Defect and Excess of Formation,     .....   130
     § 2.  Deviations of Size,        .      .       .       .      .       .       131
     2 3.  Deviations of Form,    .......   132
     2 4.  Deviations of Position,     ......       132
     § 5.  Solutions of Continuity,        .      .       .       .       .       .133
     § 6.  Diseases of Texture,       ......       133
Sect. IV.—Abnormities of the Pancreas, and the other Salivary Glands,       .   139
    2 1.  Abnormities of the Pancreas and the Salivary Glands,    .       .       139
     2 2.  Abnormities of the different Ducts and of their Contents,     .       .   141
               PART   II.

ABNORMITIES OF  THE URINARY  ORGANS.
Sect. I.—Abnormities of the Kidneys,  .
     § 1. Defect and Excess of Formation, .
     2 2. Deviations of Size,
     § 3. Deviations of Form,
     \ 4. Deviations of Position,  .
     § 5. Deviations of Consistency, .
     \ 6. Solution of Continuity,  .
     2 7. Diseases of the Tissues,
     2 8. Special Diseases of the  Investments of the
Sect. II.—Diseases of the Urinary Passages,
     2 1. Defect and Excess of Formation,
     2 2. Deviations of Calibre,
     2 3. Anomalies of Position,
     2 4. Anomalies of Texture,
Sect. III.—Abnormities of the Urinary Bladder,
     § 1. Defect and Excess of Formation, .
     2 2. Deviations of Size and Form,  .
	. 145
	145
	. 146
	146
	. 146
	147
.	. 147
.	147
; Kidneys, .	. 162
.	163
	. 163
	164
	. 165
	165
	. 168
•	168
.	• 1G9
 
CONTENTS.
    2 3. Anomalies of Position,    ......
    2 4. Solutions of Continuity,       .....
    2 5. Anomalies of Texture,    ......
Sect. IV.—Abnormities of the Urethra,       ....
    2 1. Defective Development,   ......
    2 2. Deviations of Size,    ......
    2 3. Deviations of Direction,   ......
    § 4. Solutions of Continuity,       .....
    § 5. Diseases of the Tissues,   ......
    2 6. Anomalous Contents of the Urinary Passages,


                             PART  III.

             ABNORMITIES  OF THE SEXUAL ORGANS.

                                CHAPTER I.

On Abnormities of the Sexual Organs generally,  .

                                CHAPTER  II.

Abnormities of the Male Organs of Generation,
Sect. I.—The Testes and Vasa Deferentia,  .....
    \ 1. Defect and Excess of Formation,     ....
    § 2. Deviations of Size,       ......
    § 3. Deviations of Position,        .....
    2 4. Diseases of the Tissues,   ....      .      .
Sect. II. Abnormities of the Vesiculas Seminales,
    § 1. Arrest and Excess of Development,
    2 2. Deviations of Size,    ......
    § 3. Diseases of the Tissues,   .       .      .      .      ...
    2 4. Morbid Growths,       ......
    2 5. Anomalies of the Contents of the Vesiculas Seminales,
Sect. III.—Abnormities of the Prostate,       ....
    2 1. Abnormities of Size,      ......
    2 2. Diseases of the Tissues,       .....
Sect. IV.—Abnormities of the Penis,       .....
    2 1. Defect and Excess of Formation,     ....
    \ 2. Deviations of Size, .......
    \ 3. Diseases of the Tissues,       .
Sect. V.—Abnormities of the Cutaneous Covering of the Penis and Scrotum
    § 1. Defect and Excess of Formation,     .
    § 2. Anomalies of Size,       ......
    g 3. Diseases of the Tissues,       .

                               CHAPTER III.

Abnormities of the Female Sexual  Organs,    ....

                            The External Genitals.
Sect. I.—Abnormities of the Pudenda, . 
xiv
CONTENTS.
Sect. II.—Abnormities of the Vagina,
    2 1.  Defect and Excess of Formation,
    2 2.  Anomalies of Size,
    2 3.  Deviations in Position and Form,
    2 4.  Solutions of Continuity,
    2 5.  Diseases of the Tissues,
    2 6.  Anomalies of the Contents of the Vagina,
The Internal Sexual Organs.
Sect. I.—
Sect.
Sect.
Sect.
Sect.
Sect.
 I.—Abnormities of the Uterus,
  1. Defect and Excess of Formation,  .
  2. Anomalies of Size,
  3. Anomalies of Form,
  4. Deviations of Position, . §
  5. Deviations of Consistency, .
  6. Solutions of Continuity,
  7. Diseases of the Tissues,
 II.—Diseases of the Uterus after Parturition,
  1. On Defective and Irregular Contraction and Involution of the Uterus
      aaer Childbirth,
  2. Puerperal Inflammations,  .
 III.—Abnormities of the Fallopian Tubes,
  1. Defect,     ....
  2. Anomalies of Calibre,  .
  3. Anomalies of Position and Direction,
  4. Diseases of the Tissues,
 IV.—Abnormities of the Ovaries,
  1. Defect of Formation,  .
  2. Deviations of Size,
  3. Diseases of the Tissues,
  V.—Abnormities of the Mammary Glands,
  1. Arrest and Excess of Formation,
  2. Anomalies of Size,
  3. Diseases of the Tissues,
 VI.—Abnormities of the Ovum,
2 1. Extra-uterine Pregnancy,
2 2. Degeneration of the  Ovum,
I 3. Abnormities of the Separate Parts of the Ovum,
PAGE
201
201
202
203
203
204
206 
/
               PART I.



ABNORMITIES OF THE DIGESTIVE APPARATUS. 
 
CHAPTER I.
ABNORMITIES OF THE ALIMENTARY TUBE.
         SECT.  I.—ABNORMITIES  OF THE  MOUTH AND FAUCES.

   § 1. Beviations in Form and Size.—As  excess of development, we
have here to mention the more or less complete repetition of one or more
parts, which sometimes  advances  to such an extent that the bones of the
jaws, the mouth, and the tongue are double, "and unite in one common
gullet.    As defective  formation,  which may  generally be distinctly
traced to an  arrest of development, we meet  with complete absence of
the cavities  of the mouth and fauces (astomia), or imperfect development
of individual parts, as  of the superior maxilla, giving rise to an imper-
fect development of the face (ateloprosopia), of the lower jaw (agnathia
and atelognathia), of the lips (achelia and atelochelia), of the tongue, &c.
   The most common and important cases of  arrest of development are :
Fissures of the upper  lip,  on either or both sides of the mesian line,
corresponding to the union of the intermaxillary with the superior max-
illary bones, which may or  may  not  present  a fissure also (harelip,
labium leporinum);  fissures of the  palate, caused by the absence of the
os incisivum and the middle portion of the upper lip, or by the mere dis-
union of the palatal processes in  the middle line ; or again, by defect in
the latter on either or both  sides, with or without an accompanying ab-
sence of the os  incisivum ; the fissures of the soft palate, varying equally
in degree, from complete division to a mere indication of the anomaly in
a slight notch of the uvula.   Fissures of the tongue are extremely rare,
and seldom  present more than a mere trace  of division; fissures of the
nether lip, and of the lower jaw in the mesian line, are equally rare.
   Closure of the mouth (atresia  oris) is a rare occurrence, as contrasted
with the frequency of a similar condition at the anus.
   Numerous morbid processes are  followed by anomalies that resemble
the above congenital malformations, such  as  partial  or total loss of the
lips, of the  cheeks, of the palate, contraction of the mouth to a degree
approaching atresia, adhesion of the cheeks to the maxillse, of the tongue
to the cavity of the mouth, contraction of the fauces, &c.
   Increase  of size,  as  a result  of hypertrophy, occurs  chiefly in  the
shape of hypertrophy of the lips and the tongue;  it varies in  degree,
and is peculiar to the scrofulous  cachexia and to cretinism;  it is  also
presented as hypertrophy of  the tonsils, and of the glandular stratum
of the soft  palate, as hypertrophy of the uvula, and occasionally of the
gums.
  VOL. II.                          2 
18
ABNORMITIES  OF  THE
   The opposite condition, i. e. diminution of size and, taken in reference
to the  capacity of the oral cavities and the fauces, contraction, occurs in
an eminent degree in the shape of atrophy of the tonsils, and also of the
other muciparous glands, and of stenosis of the isthmus faucium.   The
latter results from cicatrization of syphilitic and scrofulous ulcers, and
occasionally proceeds to such a degree that the isthmus  scarcely permits
the passage of a pea.


   §  2.  Textural Biseases.—Of these, inflammatory processes, and espe-
cially  those  affecting  the  mucous membrane  and  its  glands, demand
primary consideration.
   Catarrhal inflammation is particularly liable to attack the pharyngeal
mucous membrane, and to be  associated with a marked affection of  the
tonsils, in the  shape  of cynanche tonsillaris.  It  is  either  acute,  or
chronic, is apt to return, and become habitual; it frequently, and in
many individuals constantly, passes not only into superficial ulceration,
but even into phlegmonous inflammation and the formation of abscesses
in the tonsils; or it leaves a permanent relaxation of the fauces, with a
varicose state of the  vessels, elongation and oedema of the uvula, chronic
hyperaemia, and  tumefaction  of  the tonsils, and  blennorrhoea of  the
tonsils  and fauces.   It frequently extends to the mucous membrane of
the rima glottidis and of the larynx, as well  as to that of the Eustachian
tube.
   The  croupy process of the mucous membrane of the mouth and fauces
occurs,  in the  first  instance, in  the well-known  form of thrush and
aphthae in children ; and in adults, commonly with an epidemic character
of an adynamic septic type, as malignant  (gangrenous, aphthous) sore
throat  (angina  gangraenosa,  the  diphtheritis of Bretonneau).  In  the
former case, after a  previous vivid or dark  purple  reddening of one or
more papillae, and the  vesicular elevation of the epithelium at the  point
and the sides of the tongue, dots or patches, of the size of a lentil or
pea, appear on  the inner surface of the lips and cheeks, and finally, on
the mucous membrane of the fauces.   They present  an exudation, which
has a frosted, or flocculent, or villous  appearance, or is  more of a mem-
branous character, and extends into the cavities of the follicles ; it is of
a grayish, or yellowish-white color,  and of a lardaceous,  or soft, creamy,
or fluid consistency; if removed, a shallow excoriated  depression, sur-
rounded by  an inflamed  margin, remains,  on  which the exudation is
repeated,  involving a further destruction of the mucous tissue.
   In the second instance, livid spots, which rapidly coalesce, and become
invested with a dirty,  gray, shaggy,  pultaceous and sanious  exudation,
form upon the softened, bleeding gums, and the mucous membrane of the
cheeks, the  fauces, and the tonsils.  The  gums themselves  ultimately
degenerate  into  a bad-looking, pulpy, sanious  mass,  and the  mucous
membrane of the cheeks  and  fauces, underneath the exudations, is
equally found converted into a friable, fetid  pulp, or a firm slough.
   These processes often extend  to the pharynx  and  the  oesophagus,
though scarcely ever to  the  respiratory passages;  they are sometimes 
MOUTH  AND  FAUCES.
19
complicated with exudative processes on other mucous and serous mem-
branes.
  Genuine (primary) pharyngeal croup occurs rarely; it is  either the
result of an  extension of tracheal  croup, or, similar to exudative pro-
cesses  with products of a different nature, an anomalous process of a
specific,  acute, exanthematic, impetiginous,  typhous character, or it is
the result of a spontaneous or purulent disorganization of the blood.  It
not unfrequently leads to acute gastric softening.
  Pustular inflammation occurs in  the fauces in variolous disease; the
mucous membrane  being tumefied,  and invested with a plastic mucous
secretion.
  There are  other  circumscribed inflammations of the buccal and pha-
ryngeal mucous membranes, which are remarkable for their tendency to
pass into ulceration, viz. the syphilitic, syphiloid, mercurial, and scrofu-
lous inflammations.   They are generally characterized by their peculiar
red tinge and defined edges, and give rise to various products which dis-
solve the tissues in  a  peculiar manner,  and  consequently  to specific
ulcers.   Syphilis, more particularly,  is, in this phase  of its existence,
and so far as the alimentary tract is concerned, limited to the fauces.
  The last-mentioned ulcers and aphthous ulcerations, give rise to more
or less considerable loss of substance in the  mucous  membrane and the
subjacent tissues, after  the cure of which, white, indurated, elevated re-
tiform, and tendinous cicatrices remain,  which induce a corresponding
contraction.
  Among the inflammations attacking individual structures, we have to
mention  inflammation of the gums, especially the rheumatic variety, with
coexisting  affection of the alveolar periosteum,  as  also  the  scorbutic
forms and the inflammation of the tongue with its  occasional termination
in deep-seated suppuration.
  An important disease that we must here speak of, is noma, a phage-
denic ulceration which commences at the inner surface of the cheek, and
rapidly spreads, involving the soft parts in gangrenous destruction.  A
livid congestion of  the mucous membrane  precedes,  corresponding with
which there is an erysipelatous  redness  externally ;  a hard tumor then
forms; the tissues  are broken up into a pulpy sanious mass, the subcu-
taneous cellular tissue is dissolved into a pale yellowish, gelatinous, oily
mass ;  the superficial integument, at the same time, becomes pale,  and is
converted into  a similar mass, or dries  up into  a  dry, brownish-black
eschar;  the  surrounding parts presenting  erysipelatous redness  and
oedema.  This process  not unfrequently spreads over the entire cheek
and gums,  denuding the maxillary bones, and involving  them in  a spe-
cies of calcination.   (Froriep.)  It is rarely met with except in children,
and commonly attacks weakly cachectic individuals; it frequently occurs
as a sequela of exanthematic diseases, and  of typhus, and  then  repre-
sents a degeneration or an anomaly in the latter.
   § 3. Adventitious  Growths.—Among these we have first to notice the
fibroid tumors  occurring on the alveolar processes  under the name of
epulis, and in the  fauces  as  polypi; they have  a broad base, or are
pediculated, are of soft or hard texture, of a rounded, oval, or lobulated 
20                   ABNORMITIES  OF  THE
form, and are  invested with  a spongy, ulcerated,  and often bleeding
mucous membrane.
   Cancerous morbid growths do not often occur, if we except two cases
in which a malignant  tumor has made its way into the  mouth  or  the
fauces from without. Cancerous degeneration of the  tonsils is peculiarly
rare, and the cases that  have been recorded as such have almost inva-
riably proved  to be instances  of  mere hypertrophy with  induration.
Still cancer  of the  lips, and especially of  the nether lip and  of  the
tongue, where  it chiefly attacks the posterior  half,  is not unfrequent;
from these points it branches out between the muscles at the floor of the
mouth,  at the  sides of the fauces down to the  neck, and on  the tongue
it gives  rise  to an  irregular, sinuous, callous, and fungous ulcer, which
is surrounded by an indurated margin of mucous tissue.

   § 4. Anomalies in  the Secretions.—We have, under  this  head, to
notice, in addition  to those already spoken  of, the  different secretions
which cover the mucous membrane of the mouth, and especially of  the
tongue, in various chronic and acute diseases, and the concretions occur-
ring in the sinuses of the tonsils.  In scrofulous subjects the tonsils  are
often  affected, in addition to hypertrophy and habitual hyperaemia, with
a  peculiar blennorrhoea,  and  the  purulent  secretion not unfrequently
becomes inspissated, so  as  to form tubercular cheesy plugs, or even
chalky concretions.   These, in their turn, keep up a perpetual state of
irritation in the tonsils.

     SECT. II.—ABNORMITIES  OF THE PHARYNX AND CESOPHAGUS.

   § 1. Befect and Excess.—It is  only  necessary to  allude to the con-
genital  absence of this passage  as occurring in acephalous monsters, to
its partial defect with  a  blind termination, its  fusion with the trachea,
to the  saccular dilatation of the canal  resembling the craw of a bird,
to its being double  in  disomatic monsters, and to the very rare occur-
rence of insulated fissures in individuals that are otherwise normally built
(Meckel).

   § 2. Acquired Abnormities of the Calibre, and the thickness of the
Parietes.—Anomalies of the calibre present themselves in the shape of
dilatations or contractions.
   Bilatation may affect the  pharynx  and oesophagus throughout,  or
almost throughout, and give them a cylindrical or a fusiform appearance;
when  it affects the  oesophagus, it may be  partial,  in  which  case  either
pouches are formed, which involve all the coats of the oesophagus, and
which may be developed  at all points of its circumference ;  or the mu-
cous membrane alone dilates, giving rise to diverticula or herniae of  the
mucous membrane through the muscular coat.
   The first variety  has only been observed in a few  cases, though when
it occurs it is developed to an advanced degree, and presents  thicken-
ing of the parietes, and particularly hypertrophy of the muscular coat.
It appears to be sometimes  the consequence of concussion of  the oeso- 
PHARYNX AND  OESOPHAGUS.
21
phagus  by a blow or contusion of the chest.  One preparation, in  the
Viennese collection, presents  an oesophagus large  enough to allow the
passage of a man's  arm;  in another  case (Hanney), the circumference
of the dilated passage was  six inches.
   Dilatations of a lower degree sometimes occur, in which the oesopha-
geal coats are in a condition of paralytic relaxation and attenuation.
   The second variety is seen  at various  points, and in various degrees,
above contractions, and especially above  scirrhous strictures.
   The third variety is rounded; or,  if it increases to a considerable
size, we find cylindrical or  conical dilatations of the mucous membrane,
occupying  the  lateral portions of the oesophagus.   They may form at
all parts of the oesophagus, but they are most frequently seen near  the
bifurcation of the trachea, and they attain the greatest  size at the in-
ferior section of the pharynx (Baillie), where  the fibres of the  inferior
constrictor  have a horizontal position.  The  mucous membrane is pro-
truded  between the muscular fibres, and  becomes  dilated  by the food
that enters ; it is at last forced out in the shape of a cylindrical appen-
dix, which lies  between the vertebral  column  and  the oesophagus, in  a
line with the axis of the pharynx, so  that  all ingesta pass into it, and
death from  starvation results.
   The origin of the diverticulum is in many cases peculiar;  thus Ave are
acquainted with an instance in which the mucous membrane of the oeso-
phagus was dragged out in consequence of the shrivelling of an adherent
tracheal gland.
   The fauces and the oesophagus are  not unfrequently subject to con-
traction, from  being  compressed  by  the enlarged thymus gland, by
aortic aneurisms, adventitious growths, &c.; but the contractions result-
ing  from textural changes in the coats are of more importance, and
among  these we must more particularly allude to  stenoses brought on
by cicatrization after corrosion by caustic  substances, and by cancerous
affections (cancerous stricture).  Of both we shall have further occasion
to speak in the sequel.

   §  3. Anomalies of Position.—Among these we may reckon the posi-
tion of the oesophagus to the right of  the spinal column, accompanying
a  lateral transposition  of  the  intestines, the changes  produced by cur-
vatures of the  spine, the flexures or  dislocations of the pharynx and
oesophagus, brought about by hypertrophy of the thyroid gland, by
aneurisms, abscesses, morbid growths,  &c.

   § 4. Solutions of Continuity.—Among these we reckon, besides wounds
of the pharynx and oesophagus, by means  of  fire-arms, or other pene-
trating instruments, the injuries  and perforations caused hj foreign
bodies that have been swallowed, the perforations from softening, ulcera-
tions, gangrene, or from absorption in  consequence of pressure, e.g.,hj
aneurisms, by which means the most  various  passages, communicating
with the neighboring serous cavities, the respiratory organs,  the  adjoin-
ing  vascular trunks, &c,  may be established, and lastly, those very
rare occurrences of spontaneous rupture, without previous alteration in
the tissue. 
22
ABNORMITIES OF
  ^ §  5.  Textural Diseases.   1.  Inflammation. — Catarrhal inflamma-
 tion  :—This is rarely seen very intense in the acute, but certainly not
 uncommonly in the  chronic form.  The appearances  produced in that
 case are oedema of the  mucous membrane, with  a dirty-brown or slate-
 colored tinge, enlargement  of the follicles, blennorrhoea,  and an exu-
 berant formation  of  epithelium, and hypertrophy of the muscular coat.
 It is possible  that when the cardiac orifice  is the seat of inflammation,
 the consequent hypertrophy of the circular fibres, and the narrowing
 of the passage, may give rise to those enormous dilatations of the oeso-
 phagus, of which  we have already spoken.  It frequently  occurs  as  an
 idiopathic, but also  as  a secondary affection, and in the  latter case
 chiefly in  connection with impetigo.1
   Croupy (exudative) inflammation—occurs as  an  aphthous process  in
 children, as true  diffused croup, coexistent with, or unaccompanied by,
 croup of  the tracheal,  bronchial,  and  pulmonary (pneumonia)  mucous
 membrane, mainly in typhoid cholera, but also as a secondary affection
 and as an abortive exanthematic and typhoid process, the product of a
 purulent condition of the blood, brought on  by tubercular and cancerous
 cachexia.
   Pustular inflammation :—To this class belongs the rare occurrence of
 varioloid pustules, the pustules of metastatic  herpes, and  the pustules
 which occur at_ the lower third of  the oesophagus  in consequence of the
 internal administration of tartar emetic  in large doses.
   In addition to the  above varieties, we meet with  inflammation, which
 is produced by the corrosion of caustic substances; the coexistent affec-
 tion of the oral cavity and the fauces being commonly of a lower, that
 of the gastric mucous membrane  of a higher degree.  We refer the
 reader, for an investigation of this process and its consequences, to the
 following pages, as we purpose examining  it among the diseases of the
 stomach, in reference to all the tissues we  have alluded to; at present
 we merely add, that  in  those cases in which the mucous membrane has
 been  destroyed by the energetic action of the poison, it is  replaced by
 a  serous and sero-fibrous tissue, which gives rise  to peculiar valvular
 and annular strictures of the  oesophagus, somewhat analogous to those
 consequent upon dysentery.
   2.  Softening.—Softening occurs at the lower third of the oesophagus,
 and is commonly associated with softening of the stomach.    On account
 of the identity of  the two affections, we refer the reader to the section
 on the Diseases of the Stomach; the more, since the process is observed
 more  frequently in the  latter, if not  in a more  fully developed form.
 We must however  add, that it is particularly liable to affect the left side
 of the oesophagus, and then to cause perforation, in consequence of which
 we have destruction of the cellular tissue and the left mediastinum  and
 effusion of the gastric contents into the left pleura.
 ^  3.  Morbid growths.—a. Anomalous fibrous and fibrocartilaginous
tissue occurs as a  fibroid  or  fibro-chondroid tumor, in the  shape  of  a

  1 [To render this passage intelligible, it may be well to remind the reader of the theory
very prevalent among German pathologists, which attributes the majority of chronic diseases
to dormant or suppressed cutaneous eruptions.  Autenrieth may be mentioned as the chief
supporter of this doctrine.—Ed.] 
THE  PERITONEUM.
23
movable  bluish-white concretion, varying in size from a pin's head to a
kidney bean, and occupying the submucous cellular tissue of the oesopha-
gus ; and also as a fibrous polypus, attached  by a neck to the perichon-
drium of the cricoid  cartilage, and depending from it into  the oesopha-
gus ; the free surface is frequently lobulated, and it is invested by mucous
membrane.1
   b.  Tubercular  deposits are  rarely, if ever, found in the oesophagus,
and they must not be confounded with the tubercular degeneration of the
neighboring lymphatic glands.
   c.  Carcinomatous affections, in the shape  of scirrhus and medullary
sarcoma, are more frequent.  This is generally a primary disease, though
the oesophagus may become secondarily involved in carcinomatous  de-
generation of the mediastina.   In the former case the  cancer may be
found in  every portion of the pharynx and oesophagus; but the upper part
of the thoracic portion of the latter, and the inferior part of the former
appear to be more frequently attacked than the cardiac  portion of the
tube.  The degeneration generally affects the  circumference of  the pas-
sage, and thus gives rise to  annular  stricture, the extent of which must
correspond to the extent of the carcinomatous deposit.   The oesophagus
soon becomes fixed  by the adhesion  of the diseased mass to the  spinal
column.   The  metamorphosis  of the morbid product frequently gives
rise to the formation of large sanious cavities, the carcinomatous parietes
of which are covered with fungoid granulations, and with which the oeso-
phagus communicates above  and below in a transverse or slanting direc-
tion.   The sanious discharge frequently causes ulcerative destruction  of
the neighboring tissues,  by which means communications  are established
with the trachea and the bronchi; occasionally even the arterial coats,
which are otherwise endowed  with great power of  resisting such influ-
ences, become involved,  and communications with the  arterial trunks  in
the vicinity,  and more especially with the aorta and the right pulmonary
artery,  are established.
   Cancer of the oesophagus generally occurs in an isolated form,  i. e.
without  a coexistence of the  disease in other organs.

   § 6. Foreign Bodies.—Sometimes small hard bodies, such as  cherry-
stones, give rise to serious occurrences, by causing, at different  parts  of
the oesophagus, but chiefly at the lower constrictor of the pharynx (Bail-
lie), the  formation of diverticula.   Very large and hard  bodies, such as
are sometimes swallowed by  lunatics, remain fixed at a certain spot, and
may cause inflammation and suppuration;  or, by extreme pressure, even
give rise to  gangrene and perforation of the oesophagus. ^  Pointed  and
rough bodies, and especially needles  and fish bones, are still more likely
to produce perforations of the oesophagus in different directions, and  to
reach the aorta or trachea.

            SECT. III.—ABNORMITIES OF THE PERITONEUM.

   § 1. Befect and Excess of Formation.—Arrest of development in  the
peritoneal sac occurs in  the shape of fissure  in the mesial line, or exter-
1 Oestr. Jahrb. xxi. 2. 
24
ABNORMITIES  OF
nal to it; in the case of the diaphragm being absent, of a fusion with the
pleura; as defective  development of the mesentery at various points,
as defective  development or complete  absence of several other  folds,
the omentum, the appendices of the omentum, as deficiencies in  these
parts, &c.
   Excess of development frequently occurs in the shape of unusual length
of the duplicatures, e. g. of the omentum, the mesenteries, &c, or  of su-
pernumerary folds and  peritoneal  pouches.   These are  chiefly found in
the hypogastric, and more especially in the  iliac and in the inguinal re-
gions, and  near the fundus vesicas.  There  is access to these sacs  by a
well-defined fissure or ring, which is frequently surrounded by a tendinous
band, lying in the duplicature.   In the  case of their inclosing portions
of the intestine, they may give  rise to internal incarceration, which, on
the one hand, resembles external  hernia, on the other,  does not afford
the diagnostic  signs  peculiar to  this  affection, and  may, therefore, be
considered  as forming a transition  between external and internal hernia.
Similar formations, such as a delicate serous envelope of the small  intes-
tine, must  be explained by an  original  anomaly in the development of
the peritoneum.

   § 2.  Anomalies in the Size and Form of the Peritoneal Sac.—Among
these we reckon a general increase of the peritoneal surface, correspond-
ing with a congenital enlargement  of the abdominal cavity and the  intes-
tines ; the acquired extension, which may be uniform, as the result more
especially of an  accumulation of serous fluid (ascites); or partial, as pre-
sented to us in congenital or accidental hernia, and in the abnormal size
or acquired elongation of  single folds;  the  latter are brought about by
dislocations of the abdominal  contents, which  arise spontaneously, or
from a variety of causes, are most  frequently seen  affecting the mesente-
ries and the omentum, and are  of  signal importance in  reference to the
causation of internal hernia.
   A small peritoneum is the result of an arrest of  development in the
abdominal  cavity, subordinate  to  the  development of the pleura; an
apparent diminution may be caused by dislocation  of the abdominal con-
tents, as in large scrotal or diaphragmatic hernia.
   The anomalies of form  are involved in the above anomalies of size.

   § 3. Solutions of Continuity.—The peritoneal sac is liable to solutions
of continuity from penetrating wounds of the abdomen, from the effect of
powerful concussion, of excessive bodily exertion, from spontaneous rup-
tures of the hollow or parenchymatous organs it invests, in consequence
of traumatic injuries, from contusion, rupture, and separation of the sub-
jacent tissues.   The extent and nature  of the injury vary as much as its
situation.

   § 4.  Abnormities of the Tissues.   1. Hyperemia.—Hyperaemia is
either general, or, when caused by the  congested  state of an organ in-
vested by the peritoneum, partial.  It gives rise, on the one hand, to an
increase of secretion and to dropsical accumulations in the  peritoneal
cavity ; on the other, to hypertrophy and thickening of the serous  tissue, 
THE  PERITONEUM.
25
and to the development of a subserous fibroid or fibro-chondroid growth.
The peritoneal investment of the spleen offers the best illustration of the
latter.
  2.  Inflammation (Peritonitis).—Inflammation  of the peritoneum pre-
sents  the symptoms common to inflammation of serous membranes.  It
may occur as an idiopathic affection, or in consequence of traumatic lesions
of the abdomen, of pressure from incarceration, or from contact with the
atmosphere, with the  contents of the stomach or  intestines, with bile,
urine, vaginal  secretions, blood, or pus.  It may be presented to us in
the form of  spontaneous or rheumatic peritonitis;  it may occur as the
result of a propagation of disease from the organs contained in the peri-
toneal sac.  The most frequent form is the one attributed to metastasis,
in which the peritoneum, from the large serous  surface which  it offers
(and in  this respect it  presents an analogy with the  vast tract of the in-
testinal mucous membrane), and, owing to its proximity in many cases
to the  primary seat  of disease, is converted into a focus of extensive
exudative process.  To this class we refer more particularly the inflam-
matory and exudative processes of puerperal fever, of  which we shall
have  occasion to speak more fully at a future period.
  The affection is either general or partial.  In the former case, it in-
volves the peritoneum of the abdominal parietes, of the parenchymatous
viscera, and of the colon (enteritis peritonealis), though generally with a
predominance in  one or the other.   In both it may appear in the acute
or chronic form.
  Acute general peritonitis very often terminates fatally, with symptoms
of intestinal paralysis, and with imminent or existing ileus; or death is
caused by exhaustion, which gives rise to the formation of large fibrinous,
puriform and purulent exudations.   We then find, in addition to the
symptoms of serous inflammation, an enlargement of the intestine; it is
expanded by gases (tympanitis), by thin watery  and  feculent matters;
the coats of the intestine, and chiefly the interstitial cellular tissue and
the mucous membrane, are tumefied, the muscular layer is pale, and they
are all fragile and friable.
  The tumefaction of the intestinal coats is commonly owing to an infil-
tration of the tissues  by a watery fluid, and  increases in  proportion to
the degree  in which   the mucous membrane participates in the exuda-
tive process.   It occurs in the most  exquisite degree in the so-called
metastatic  form, in that inflammation of the peritoneum which is the
local  expression of a  general disorganization of  the  blood, i. e. in the
puerperal type.  In this case the mucous membrane presents a relation
similar to that exhibited by the peritoneum in exudative processes of the
mucous membrane, in Asiatic cholera, in colliquative diarrhoeas gene-
rally, or in dysentery in the shape of a mucous secretion, or of a delicate
indication of plastic exudation, evidenced by mere loss of  brilliancy and
smoothness.
  The ileus,1 which occurs in general peritonitis, is, like the dilatation of
the intestine, the consequence of paralysis of the muscular coat; a rela-
tion observed to exist  wherever muscular fibres are subjacent to seroua
1 Vide  Oestr. Jahrb. xviii. 1. 
26
ABNORMITIES  OF
membranes.  The exudation of plastic lymph, especially in the case of
various abnormal contortions,  is also likely to contribute to  its occur-
rence by binding down the intestine.   We may easily infer which will
be the terminal point of the antiperistaltic movement, or of ileus, in cases
of enteritis peritonealis.  As the inflammation of the  peritoneum is ac-
companied by paralysis of the  entire intestine, it can be no other portion
of the intestine than the duodenum, at the lower end of which the peri-
toneum, and consequently the inflammation and paralysis, terminate, and
which by itself is, under no circumstances,  capable of controlling, by its
peristaltic action, the accumulated contents of the small intestines which
are being  thrown into  it.   Yet  cases which, like puerperal peritonitis,
are generally accompanied by diarrhoea, form exceptions to this rule.
   The exudations  seen  on  the peritoneum,  exhibit,  in  reference  to
quantity and minute structure and to their metamorphoses generally, all
those variations which  we have cited in the general remarks on inflam-
mation of serous membranes.   The general remarks there made with re-
gard to the acute and chronic forms of  the process, are equally applica-
ble here.  Nevertheless, we observe numerous peculiarities in peritonitis,
to which we must here advert.  We very frequently find extensive ca-
coplastic,  disorganized, discolored, septic  exudations,  accompanied  by
an almost imperceptible increase of redness and vascularity; they are
more especially associated with puerperal, septic processes in the uterus.
Plastic exudations become organized into cellular or cellulo-serous tissue.
This remains attached  to the peritoneum in the shape of a pale, grayish-
white, or  bluish-red  and  vascular, or slate-colored  accumulation; or it
forms a new movable cellulo-serous investment to all  organs  enveloped
by the peritoneum, or  it assumes the shape of flakes  or  strings, which
pass from one to the other in different directions.  In the  two  latter
cases, various tense  or loose adhesions between the abdominal viscera,
among themselves, or with the parietes of the abdomen, will  result; of
these the following are the chief:
  Adhesions of the intestinal coils, producing  very manifold  transposi-
tions among themselves,  and with the mesentery, with the colon,  in re-
ference to the hypogastric  parietes of the  abdomen and the  pelvis,  the
bladder, and the internal sexual organs of the female ;—adhesions of the
omentum in various degrees with the hypogastric parietes of the abdomen,
and more particularly of the inguinal region, and with the internal sexual
organs of the female ; the omentum may be folded together, or rolled up,
and stretched across in a slanting direction to either of the inguinal re-
gions, or it may descend with a furcate fissure to both, so as to attach
itself at these points, and form a vertical, or, if passing under the colon
transversum, a rounded horizontal band; thus giving rise to a species of
diaphragm, which separates the mesogastric and hypogastric regions;—
and adhesions of the parenchymatous  viscera to the  adjacent parietes
and to the neighboring viscera.
  Adhesions between the omentum and the colon,  and the anterior pa-
rietes of the abdomen, are found chiefly in chronic peritonitis, but they
are not of frequent occurrence.
   The corded exudations may, in various ways, cause incarcerations of
the intestine. 
THE  PERITONEUM.
27
   Or the exudations undergo metamorphoses, so as to give rise to tendi-
nous or fibro-cartilaginous laminae, sometimes of uniform thickness, and
with defined edges, sometimes of areolar or cribriform structure, at others,
uneven, lobulated, granulated, thinning  off towards  the  circumference,
glued on to or fused with the thickened peritoneum.   This is remarked,
principally, on the omentum and  the  fold of the intestine  in hernia, or
on the hernial sac itself, and also  on the convex surface of the spleen, on
the liver, sometimes on the uterus and its appendages, and in rare cases
on the entire  extent of the peritoneum.
   The chronic form of inflammation, which  affects  the  exudations that
have already been deposited, and creeps on with occasional exacerbations,
presents the  following peculiarities:   It occupies the  intestine only;
or at least that part of the circumference of the intestine chiefly which
is not affected by adhesions resulting from a previous process, as well as
the opposed parietal surface, which in various  degrees is limited by, or
free from, adhesions.   The consequence is the formation of a coagulum,
which covers the anterior surface  of the already agglutinated intestines,
passing from them to the parietes, and thus inclosing a sacculated space
which contains the fluid portion of  the exuded matter.   In such a case
the intestines, and more particularly the small intestines, form a flattened
round mass, riding upon the  vertebral column, and invested anteriorly
by the posterior lamina of a pseudo-membrane, which  contains  in its
cavity a varying amount of fluid.
   Hemorrhagic exudation is frequently seen on the peritoneum; it forms
large, saturated coagula, disposed in thick layers.   Thin strata present
a  deep black or bluish-black discoloration, the effect of the intestinal
gases.
   Peritonitis  occasionally terminates  in  suppuration or gangrenous de-
composition, phthisis and gangrcena peritoncei.  With the exception of
those cases, in which purulent or gangrenous disorganization  and  per-
foration result from a propagation of the disease from other tissues, this
termination occurs under the  following conditions:
   a. The peritonitis itself yields a  purulent exudation, and the perito-
neum is destroyed by suppuration, followed by the denudation and sup-
puration of the subjacent tissues.  This occurs chiefly in partial, circum-
scribed peritonitis, when the  exciting causes, viz., suppurative inflamma-
tion or gangrenous  infiltration of an  organ, accompanied by a purulent
or ichorous discharge on the  peritoneal surface, continue.
   b. Occasionally a certain portion  of a fibrinous exudation does not be-
come organized, but being diffused through the interstices of the adven-
titious membrane,  melts into  a creamy pus, which, being in close contact
with the latter, produces at once in it and in the peritoneum suppurative
inflammation and suppuration.
   In either case, ulcerative  perforation of the intestine or of the ab-
dominal  parietes frequently  proceeds  from the  morbid process in the
peritoneum ;  and when, as is sometimes the  case, both occur simultane-
ously, fistulae  result.
   Partial peritonitis in many cases appears to be a molimen naturae des-
tined to circumscribe destructive processes, to arrest imminent or existing
discharges which are hostile  to the integrity  of the peritoneum.   To 
28
ABNORMITIES OF
these belong, first of all, the  circumscribed  inflammations of the  peri-
toneum, which take place in the vicinity of approaching or existing per-
forations of the stomach, the colon, the vermiform process, in the vicinity
of purulent accumulations external to the peritoneum, threatening per-
foration and discharge into the peritoneal cavity, and the like.  By this
means, general peritonitis, and a consequent rapid and fatal termination
are frequently postponed for  a long time; yet, whilst the exciting cause
continues, peritoneal phthisis, with its consecutive disorganization, must
ensue ; or the adhesions which limit the focus of inflammation give way,
and, in  consequence of the free discharge of its contents, general peri-
tonitis follows, or this may take place without the occurrence first men-
tioned, in consequence of the violence and  extent of the  inflammatory
process at the original seat of the disease.
  Gangrene of the peritoneum occurs as a yellow slough, in consequence
of pressure or  traction caused by external or internal  hernia, in conse-
quence of its being  deprived of the  subserous cellular  tissue where  it
overlays  perforating  ulcers of the intestines  and abscesses ;  or as gan-
grenous  disorganization and  conversion into  a blackish, moist, ragged,
and friable tissue.
  3. Heterologous formations, a. Anomalous occurrence of cellular and
of serous tissue.—This appears on  the peritoneum in  the shape of the
above-mentioned organizing processes of a plastic character, and especially
as serous cysts, in which case  the pseudo-membrane includes, during its
organization, a portion  of the fluid exudation, and receives an internal
serous investment.   Such bladders are either  connected with the peri-
toneum by means of a neck  or stalk, or adhere to it  by a broad  base.
In rare  cases we find cysts with various contents as new formations on
certain portions of the  peritoneum, and then  most frequently  on the
omentum.
  b. Anomalous fibrous (fibro-cartilaginous) tissue—owes  its  origin to
the inflammatory process in a similar manner as that above  described.
But there are, besides, other  instances of  the  occurrrence of this tissue,
in the shape of fibro-cartilaginous smooth or lobulated  laminae, project-
ing granulations, &c, occupying the subserous layer of the peritoneum.
They are observed in old hernial  sacs; rarely, as compared with the
pleura, on  the parietal, but very frequently on certain  portions of the
visceral plate of the  peritoneum, owing to the hyperaemia which takes
place here, as, for instance, in the case of the spleen.  This tissue also
occurs in the subserous cellular tissue of the uterus  and its appendages,
and on the colon in the shape of a fibroid growth; in the former case, it
reaches  a considerable magnitude ; in the  latter, it  rarely exceeds that
of a lentil or a pea.
  c. Anomalous  osseous tissue—is developed from the above-mentioned
tissue in the shape of compact, smooth, or uneven lobulated plates  of
varying thickness.  The fibroid growth in the subserous cellular tissue
of the intestinal canal is very rarely the seat of ossification.
  d.  Tubercle.—Tuberculosis of the peritoneum occurs in the various
forms of which we gave  a general sketch when treating  of the  tuber-
cular disease of serous membranes,  both as an acute and as a chronic
affection.
• 
THE  PERITONEUM.
29
   It is very frequently found in the circumscribed form on those parts
 of the peritoneum which correspond with tubercular ulcers of the mucous
 membrane;  and we here trace all the forms peculiar to peritoneal tuber-
 culosis generally.   It  commonly does not appear until the secondary
 tubercular infiltrations have extended from the inner surface of the intes-
 tinal tube into the muscular  coat, and  thus  involved the  tissue  of the
 peritoneum itself.
   The tubercular exudations  on the peritoneum likewise give rise to all
 the  adhesions we have  above  spoken of, generally producing a more inti-
 mate agglutination between the viscera.  Peritoneal tuberculosis  occa-
 sionally appears as a primary affection, the peritoneum  being the  first
 tissue attacked by tubercular  deposit; but it occurs more frequently after
 the  cachexia has been evidenced by tuberculosis, of another organ.   Thus
 it allies itself to pulmonary, intestinal, and cerebral tubercle, and it very
 commonly terminates in tubercular affections  of the abdominal lymphatic
 glands, and  in  the  female sex more particularly  in  tuberculosis of  the
 uterine and vaginal mucous membrane.   The acute forms of peritoneal
 tuberculosis are, in most cases, complicated with a corresponding affec-
 tion in the spleen, the liver, the kidneys.
   The reflected action upon the adjacent muscular fibre, which occurs in
 peritoneal inflammation, is presented to us in a much higher degree in the
 tubercular exudative process.   We find that the intestinal coats, in addi-
 tion to being tumefied, become very friable ;  there is increased exhala-
 tion from the inner surface of the intestine, and liquefaction of its con-
 tents* the muscular coat becomes pale, is easily lacerated and broken  up,
 and even the muscles of the abdominal parietes waste and lose color.
   Peritoneal tubercle, and especially the granulated variety, rarely passes
 into the stage of softening;  when it does so, it may cause  tubercular
 suppuration  or  peritoneal  phthisis, and  consequently phthisis  of other
 adjacent tissues; cretification is a still more unusual  occurrence, but  the
 tubercular disease frequently  becomes stationary.
   e.  Carcinoma.—The peritoneum is either secondarily affected by car-
 cinoma, a cancerous growth  originally  generated externally to it,  ap-
 proaching and involving it in  its metamorphosis, perforating it and pene-
 trating into its cavity ;  or the carcinoma is produced without such ante-
 cedents,  though commonly occasioned by a carcinomatous affection in the
 neighborhood, in the vicinity  of which it is formed;  or, lastly, it occurs
 in some rare cases, altogether independently of such causes, as a primary
 affection of  the peritoneum.  It must, therefore, with the  exception of
 the last-mentioned unfrequent case, be considered as the product of can-
 cerous cachexia which has already found a nidus and a local habitation.
   The most common form of  carcinoma, into which,  however, the other
 carcinomatous growths, which give rise to its appearance on the perito-
 neum, usually degenerate, is the areolar, and, second  in  order, the me-
 dullary species.
   The former appears as a hard, crystalline, transparent, and  discrete
 cancerous follicle, resembling tubercle, and of the size of a hemp or millet
 seed; in the acute variety it is generally thickly  sown over a large ex-
tent, and even spreads over the entire peritoneum, or it occurs as a layer
of areolar cancerous  tissue, varying in thickness, or  as a circumscribed, 
30
ABNORMITIES  OF
round, lobulated aggregation.   The omentum is very commonly found to
shrivel up and to degenerate into a transverse band, or, in the opposite
case, with an enormous increase of size, into areolar cancer.
  Medullary carcinoma frequently occurs in the acute form, as the white
or colored (melanosis) encephaloid variety, either  deposited in layers, or
more commonly as compressed, rounded, medullary nodules, of different
dimensions.
  In  the fibro-carcinomatous  degeneration  of the  peritoneum and its
subserous cellular tissue, which occasionally extends over the entire peri-
toneum, we invariably perceive an atrophy and condensation of the tissues,
and, in consequence, a contraction of the carcinomatous folds of the peri-
toneum, e. g. in the mesentery.
  Peritoneal cancer is commonly complicated, in  the manner  above  de-
scribed, with gastric intestinal  and ovarian cancer,  and  then also with
uterine and  hepatic cancer,  the medullary form prevailing in the latter
case.   We  must  not omit to  allude,  at this  place, to  the  nodulated
retro-peritoneal cancerous formations of Lobstein, which  commonly take
their origin  in the glands of the lumbar plexus or other subordinate por-
tions of the  absorbent system,  and which extend into the mesentery.

  § 5.  Morbid Contents of the Peritoneal Cavity.—In reference  to this
subject we may direct the reader to the preceding remarks, to the general
investigation of the abnormities of serous membranes, and to subsequent
paragraphs.  At this place we merely  allude to  the presence  of  gas
(meteorismus abdominalis) and of  serous fluid (ascites) in the peritoneal
cavity.   The former occurs  in rare cases as a joint product of the inflam-
matory process, or as the result of decomposition affecting an exudation
of low vitality, and in extremely rare cases as the product of a deranged
secretion ; but it is more frequently a mere extravasation of intestinal gas,
resulting from rupture, gangrene,  ulceration, or softening of the stomach
or intestine.
  Extensive accumulation of serous fluid gives rise to ascites.   It is very
often the result of an hydropic  cachexia, dependent upon a variety of
causes, and  is then commonly associated with  other dropsies.  In  the
first instance, the predominant hydropic  symptom  is mostly the conse-
quence of granular liver, heart-affections, frequently of Bright's disease
of the  kidneys; it  accompanies carcinomatous formations on the peri-
toneum, &c.

              SECT.  IV.—ABNORMITIES OF THE  STOMACH.

  § 1.  Original arrest of development  of the stomach involving  at  the
same time a large portion of the intestinal canal is found in very imper-
fect monstrosities,  and more  particularly in acephalous foetuses,—the
stomach  is  occasionally absent  in individuals otherwise normally built
and provided with a well-developed' intestinal tube, or it may only be
indicated by a small saccular dilatation of the oesophagus.

  § 2.  Beviations of Size.—Congenital malformations belonging to this
class,  are either unusual enlargement, or unusual  diminution of size; the
latter peculiarly affecting the female sex. 
THE  STOMACH.
31
   Either of these conditions, but chiefly the abnormal increase in size,
occur likewise as acquired diseases.
   Dilatation of the stomach is either spontaneous, or it  is caused  by
stenosis.  The former variety presents a uniform increase of size, and
sometimes acquires such a surprising extent, as to fill the entire abdomi-
nal cavity.   Repeated repletion, in consequence of a morbid  appetite,
may give rise to this development, or it may occur as a result of para-
lysis from concussion, traction, or dislocation produced by large scrotal
herniae, and it kills slowly with vomiting, with or without gangrene of the
mucous membrane, under symptoms of complete paralysis.
   Dilatation from stenosis varies according to the seat of the latter.   In
common stenosis  of  the pylorus, it is  mainly developed at the  splenic
portion; it equally reaches an enormous degree, and proves at last fatal
by paralysis.   When stenosis occurs at a different spot, more or less con-
siderable saccular dilatations take place in other sections of the stomach,
and in different directions.
   A diminution of the stomach is sometimes  produced as a permanent
condition in consequence of an  insufficient  supply of nutriment;  in
other cases it is the consequence of textural disease, especially that
produced by cicatrization of extensive ulcers.   Contractions or stenoses
are the result of  hypertrophy of the gastric membranes, of carcinoma,
particularly  when occurring at the pylorus,  and of cicatrization  after
ulcerative destruction of the tissue at this and  at other points.
   In reference to the thickness of the parietes of the stomach, we may
observe, that extreme thickness, not connected with degeneration of the
tissues, is the  immediate  consequence of the  hypertrophy of one,  or
more commonly of both of the internal  coats.   The pyloric  region is
chiefly liable to the affection, which is sometimes limited to the annular
portion; it is developed to a greater extent when resulting from stenosis
of the  pylorus, accompanied by the  above-described  dilatation, and it
then affects  mainly the muscular  fibres.   Hypertrophic  disease of the
pylorus must be carefully distinguished from carcinomatous thickening.
   Attenuation of the gastric coats not unfrequently occurs at the fundus
in consequence of extreme  dilatation of the  stomach resulting  from
stenosis of the pylorus.   The  thinning  which occurs  as  spontaneous
atrophy, or tabe3, with or without an accompanying change in the capa-
city of  the stomach, is  of greater importance; it is a very  rare and
tedious  disease, but  one which we have invariably seen  associated with
universal tabes, and with atrophy of  the  lungs (emphysema  senile) and
the heart.

   § 3.  Beviations of Form.—Among these we reckon, first of all, those
rare  congenital malformations  of the human stomach,  in which  an
annular contraction  divides it into a cardiac and pyloric stomach, or in
which two or three such  contractions form three or four sacculated divi-
sions, and thus cause a resemblance to the stomach of ruminants.  We
distinguish these from  the contractions produced during the  agony of
death,  by the fact  that  the latter may be  removed  by inflating the
stomach.
   Similar and various  other  malformations are  observed as  acquired 
32
ABNORMITIES OF
conditions;  they have their origin mainly in loss of substance and in
cicatrization of the  so-called perforating gastric ulcer, and we  shall
recur to the subject when we discuss the latter.

  §4. Beviations of Position.   Congenital.—Position  of  the  stomach
external to the abdominal cavity in eventration, and in umbilical hernia;
in the left side of the thorax, the diaphragm  being wholly or partially
absent on this side;  vertical (foetal) position, with the pylorus down-
wards ; the  position of the  fundus, in the right  hypochondrium, corre-
sponding to the reversion of the formative type in lateral translocation.
Acquired.—Protrusion of the stomach,  externally,  in  consequence of
extensive  penetrating wounds, or into  the thorax, after injuries to or
rupture of the diaphragm;  the position of the stomach  in large hernial
sacs,  especially of umbilical  and scrotal hernia; the dislocation of the
stomach  from its natural position by enlargement of the  organs in its
vicinity, by morbid products, by effusion  into the peritoneal  cavity, by
traction of the omentum  and transverse  colon;  lastly, the spontaneous
sinking of the entire stomach into a lower abdominal region from increase
of volume or weight, as in the case of a scirrhous pylorus.

  § 5. Solutions of  Continuity.—We merely  allude here to those rare
occurrences of wounds of the stomach produced by penetrating instru-
ments, and  by firearms, occasionally healing up with a fistulous  opening,
and to those circumscribed separations of the membranes of the stomach
from  one another, accompanied by extravasation of blood, which occa-
sionally result from concussion.

  § 6. Biseases of the  Tissues.—As we  have  already treated of the
diseases of  the  peritoneum, we shall now discuss those of the gastric
mucous and submucous  tissues,  and the  consecutive affections of the
muscular coat of the stomach.
  1.  Inflammation,  a.  Catarrh of the gastric mucous  membrane  (gas-
tritis mucosa).—The opportunity of observing  the  first  stages of the
genuine acute catarrh of  the gastric mucous  membrane, of the gastric-
saburral,  gastric-bilious, and allied conditions, in the  dead  subject, is
rarely, if ever, offered; we  see the blennorrhagic stage, chronic catarrh,
and the occasional acute exacerbations of the latter, more frequently.
  The latter is developed from repeated active hyperaemia,  or  from
lasting mechanical  hyperaemia, and the  gastric catarrhs  observed in
gourmands, and especially in drunkards, and accompanied by  ulceration,
and by the formation of morbid products in the stomach  in chronic
heart disease, or in pulmonary phthisis, are particularly remarkable.
The latter are generally complicated with catarrh of the entire intestinal
tract, and with bronchial catarrh.
  The anatomical signs  of  this condition are, a  dark, reddish-brown, or
slate-gray,  or even blackish-blue discoloration of the mucous  membrane,
copious secretion of a stone-colored, occasionally glassy pituita, thicken-
ing,  increased  condensation  and induration,  i.  e., hypertrophy of the
mucous membrane, which presents itself in various degrees: 
THE  STOMACH.
33
  a. In  the  lowest  degree,  the mucous membrane shows  simply an
increase of thickness and hardness in its tissue;
  /?. In a higher degree, it presents, in addition to its increased thick-
ness, an uneven, racemose, or warty surface, a surface mamellonee;
  y. In  a still  more advanced degree, it forms  prolongations  in  the
shape of permanent, firm folds,  or of polypus.
  The submucous cellular tissue, and the muscular coat, also  participate
in this hypertrophy in various degrees—the  entire  parietes of the sto-
mach presenting unusual thickness, firmness, and hardness.
  The pyloric portion  is  the  chief seat of  chronic catarrh, and it is
there that hypertrophy  of the  mucous and  other membranes is most
prominent.
  b. Croupy inflammation.—This  form never occurs as a primary and
substantive affection except in the shape of  delicate flocculent  exuda-
tions  in  the  aphthous process  of children, but always, and  even  that
rarely, as a  sequela or degeneration  of exanthematic  processes,  in
variola, in typhus, in the absorption of pus into the  circulation, and
particularly in puerperal inflammation of the  uterine veins.   The false
membrane which sometimes  invests the entire stomach, presents  a very
regular areolar surface.
  The operation of tartar emetic upon the  gastric mucous  membrane
may produce a similar process, it is however commonly  limited to a few
streaks.
  c. Inflammation of the submucous cellular tissue.—Idiopathic inflam-
mation of the submucous  cellular  tissue  of  the  stomach,  resembling
pseudo-erysipelas, and passing on to suppuration, is a very rare  pheno-
menon ;  it not unfrequently occurs as a secondary process, analogous to
the metastases of specific, acute  dyscrasiae.  The parietes of the stomach
appear thickened; the   stratum of  submucous tissue is distended with
pus;  it is soft and  friable;  the superincumbent  mucous membrane is
reddened,  and,  at intervals, tense.   After a  time it gives way at these
points, and, by numerous irregular cribriform openings, the  pus  exudes
into the cavity of  the stomach.
  d.  The process, which is caused by the operation of caustic substances
on the membranes of the upper part of  the alimentary canal.
  We limit ourselves to a statement of  the modus operandi of the more
common  substances which are taken  accidentally, or are administered as
poisons, such as the  mineral  acids, and especially  the sulphuric acid of
the shops, and white arsenic, and give the results  afforded by numerous
post-mortem examinations.
  The effect of the  mineral  acids  generally extends over the cavity of
the mouth and fauces, the gullet, the oesophagus, the stomach, and occa-
sionally beyond the latter;  sometimes it is  limited to the  former, so
that scarcely a trace is visible in the stomach.
  In reference to the intensity of  the effect which may cause superficial
or deep  mortification of the tissues with greater or less rapidity, we
distinguish several degrees.   The  effect is influenced by the quantity
and the strength of  the  liquid, and  the duration  of the period  during
which it  remained in contact  with  the parts alluded to.   We generally
find the effect to be less intense in the cavity of the mouth and fauces,
  VOL. II.                           3 
34
ABNORMITIES  OF
more  marked in the oesophagus, and, provided an  appreciable  amount
of acid reached the stomach, most powerful at this point.  In the lowest
degree the effect is limited to destruction of the epithelium.  The mucus
of the mouth and the fauces contains flocculent coagula; the epithelium
is converted into a thick, grayish-white, rugose layer; it peels off here
and there, and the subjacent mucous membrane is pale.
  In  an advanced degree, the superficial layers of the mucous membrane
of the fauces and oesophagus, under the destroyed epithelium, are found
corrugated,  of a  dirty, whitish, leaden hue,  and  the capillary network
blackened by its carbonified contents.   The lower strata of the mucous
membrane, and the submucous cellular tissue, present serous infiltration.
In the follicles at the root of the tongue, the mucous secretion is coagu-
lated  into dirty white masses.
  In  a still higher degree, the entire mucous membrane is destroyed, and
converted into a dirty gray mass, which is  traversed by black vessels;
the submucous  cellular tissue is infiltrated, and  partially ecchymosed;
the muscular coat of the oesophagus itself is shrivelled, pale, ashy.
  In the highest degree, the mucous membrane of the oesophagus, together
with  the submucous cellular tissue, is converted into a soft, black mass,
which is distended by a sanguinolent fluid, and is easily detached from
the muscular coat.  The latter is itself either  destroyed in the same man-
ner,  or is perfectly colorless, friable, and presents an ashy, gelatinous
appearance.
  The mucous  membrane of the  stomach almost invariably suffers the
changes of the third degree, though in  varying extent and thickness.  It
is either  affected in single folds, or streaks which  pass from the  cardiac
orifice to the lesser curvature, and from the large  curvature to the pylo-
rus ; or over a large extent; or we find the entire  surface converted into
a black carbonaceous mass, of several lines in thickness, distended  by
sanguinolent fluid, and consequently presenting a tumefied appearance.
The muscular coat is altered in the manner peculiar to the third degree,
and we therefore often find the parietes of the stomach perforated.
  The acid affects the neighboring  organs through the membranes, and
thus either coagulates or tans the contained fluids, fuses  the tissues into
a gelatinous mass,  or  carbonifies  them; the discoloration produced  is
always very marked.   In many cases,  not only the  blood of the neigh-
boring bloodvessels, but also of  the  larger trunks, and  even of the
aorta, is changed into pultaceous, pitchy, greasy, black cylinders. Beyond
the stomach, and especially in the  duodenum, and at the  commencement
of the jejunum, the effect of the lowest degree is exhibited in coagulation
of the intestinal mucus, and of the chyle, in  corrugation and opacity of
the epithelium, in the  tanned state of the mucous  membrane,  and the
dark injection of its vessels.  The  consequences and  results are modified
according to the intensity of the operating influence.
  The highest degrees, in which, generally, a very extensive surface is
involved, produce a rapidly fatal termination.  The  lowest  degrees are
followed by exudative  inflammation;  the mortified  epithelium sloughs,
and being replaced by a new formation as soon as the  reaction has abated,
recovery ensues.
  In  all the higher degrees we have reactive inflammation in the healthy 
THE  STOMACH.
35
tissue, which effects the rejection of the superincumbent mortified tissue
by passing into suppuration.   As the inflammatory and suppurating pro-
cesses diminish, the tissues contract, cicatrices form, and a cure results ;
or suppuration is protracted, causing a  late recovery, or ending fatally
in oesophageal phthisis.
  According to the depth to which the tissues are destroyed, the loss of
substance is repaired under  a formation of strictures, that vary in size
and consistency.
  If  the mortification be  limited by the submucous cellular tissue, we
shall  find the latter condensed over the pale, ashy, muscular coat, which
now resembles the elastic tissue, into a serous, or fibro-serous,  tissue,
replacing the mucous membrane to  a considerable extent.   This tissue
forms, at  some places, projecting ridges, or valvular,  and even annular,
duplications towards  the oesophagus; and we thus have a peculiar mem-
branous stricture of the latter produced, not unlike the strictures found
in dysentery.
  If  the muscular coat  itself is involved, it  is partially or  entirely de-
stroyed, and the walls of the oesophagus are  converted into a fibro-cellular
firm tissue, which contracts, and thus produces  the most important and
most  resisting strictures.
  These strictures are formed chiefly,  though not exclusively,  at the
lower section  of the  pharynx, posterior to the cricoid cartilage,  and in
the vicinity of the  cardiac  portion.   We also not  unfrequently see,
besides these  strictures, solitary insulated  remains of the mucous mem-
brane on the inner surface of the oesophagus, in consequence of the con-
traction of the new tissues.   They have a shrivelled appearance, and are
in part detached, or form transverse bands.
  A  torpid suppurative process is commonly the result of a more pro-
found injury, and is  seen  in  the  shape of abscesses and sinuses  of the
muscular coat, and of the  condensed cellular sheath of the  oesophagus.
When it ceases, it invariably leaves very considerable  contraction  of the
tissues and strictures  of the kind last described; ulcerative perforation of
adjoining passages (trachea, bronchi) may follow; death frequently  ensues
from  phthisis, or by exhaustion from dysphagia.
  The same occurrences may, though less frequently, be observed in the
membranes of the stomach.
  The operation of arsenic is limited to the  mucous membrane of the
stomach, but it frequently produces  no local effect;  and this  is  parti-
cularly the case where the symptoms of poisoning and death follow rapidly
after  the introduction of small quantities.  When present, it is an exu-
dative inflammatory process,  accompanied  by softening and sloughing.
At  one or  more points, to  which a white pulverulent substance  (arsenic)
happens to attach itself  to a larger amount, the mucous  membrane ap-
pears plicated and tumefied, reddened, invested by a detached epithelium,
and a tawny exudation; its tissue is softened, pultaceous ; and at the spot
where the white grains of arsenic are  attached, it is converted  into a
yellowish or greenish-brown slough.   Between these solitary foci, from
which reddened folds  of the mucous membrane proceed, the inner surface
of the stomach presents  at many parts a perfectly normal structure.
  2.  Ulcerative processes.—The ulcerative loss of substance which results 
36
ABNORMITIES OF
from one or the other of the processes we have hitherto considered, re-
quires  no separate examination,  as it presents nothing  characteristic.
There are other ulcerative affections of the stomach which appear of more
importance.  Those connected with tubercular and cancerous affections
we shall examine under the head of tubercle and carcinoma.   At present
we consider the following :
  a. The perforating ulcer of the stomach.—There is one kind of ulcer
that occurs in the stomach, which, both on account of its frequency, and
on account of the extreme pain it  causes, as well as on account of  the
numerous and enigmatical symptoms that accompany it, deserves every
attention,—an ulcer, termed by Cruveilhier the simple chronic ulcer of
the stomach, and which we would call the perforating gastric ulcer, from
its prevailing tendency to perforate the parietes of the stomach.
  In a well-defined case there is, in the region of the pylorus, a  circular
orifice  of from three to six lines in diameter, with a sharp peritoneal edge,
as if a round piece of the gastric parietes had been punched  out.   When
viewed from  within, the loss of substance on the internal membranes of
the stomach, and especially on the mucous layer, appears more consider-
able, so that the edges of the hole seem bevelled off from within outwards.
There is no further morbid appearance beyond a thickening of the parietes
in the immediate  neighborhood of the ulcer, and a tumefaction of  the
gastric mucous  membrane.
  The pyloric  half of the stomach is  the  seat of the ulcer; it is most
frequently  found in the middle  zone of this portion;  it is oftener seen at
the posterior than  at  the anterior surface, almost always near to, and
frequently at, the lesser curvature; and it occurs, in extremely rare cases
only, at the fundus.   This affection may also appear  beyond the stomach
in the  upper transverse portion of the duodenum, but it  does not occur
in the  remaining portion of the intestinal canal.
   The size of the  ulcer varies from that of  a sixpence to  that of half-a-
crown, and even to that of a cheese-plate.
   Its shape is commonly circular, but, in exceptional cases, it is from the
beginning  of an irregular form, though  the circular form with which it
commences frequently disappears subsequently.   Ulcers of  great extent
approach the elliptical shape;  but, on further extension, this too is lost,
and they become  irregular  in  consequence of the formation of  sinuses
varying in  depth.   The extension of the ulcer in the  transverse diameter
of the stomach, so as to  form a zonular ulcer, is  singular, on account of
the deformity of the stomach which follows.  The original  form of the
ulcer  is also lost, when two ulcers  coalesce so as to form a single one.
In these cases we  may for a long time be able to point out the boundaries
of each, represented by a ridge of cellular  tissue, but this,  too,  will dis-
appear, and  they then both have the same common base.
   In the majority of cases there  is only a single ulcer, but frequently
there are two or three, occasionally four or five, and  these are then com-
monly placed above  or near to one another at the  posterior surface of
the stomach, or at the lesser curvature.  It is  very  rarely the case that
one occurs at the posterior, and the other at the anterior surface of the
stomach, or that two ulcers are formed  opposite to  one  another in the
duodenum. 
THE  STOMACH.
37
  It has not been clearly ascertained in what shape the malady takes its
origin, and in what manner the further development  is effected.   It is
probable that it  commences with an acute, circumscribed, red softening
(hemorrhagic erosion), or with  a circumscribed sloughing of the mucous
membrane; it is still more probable that the ulcer increases in this man-
ner, the tissues at the base of  the ulcer sloughing and exfoliating layer
by layer.   We have observed this occurrence in a few  solitary instances,
and we would therefore view the process as offering a valuable analogy
to sloughing of the lungs (gangraena pulmonalis); on the other hand, we
cannot admit that view to  be well grounded, which explains the loss of
substance in question solely by the absorptive process; the callosities of
the surrounding tissues, and  the well-marked reaction at the base, are in
themselves sufficiently strong arguments against it.
   The ulcer attacks the  deeper-seated parts in a peculiar manner, when
it presents the perfectly round form.  The loss of substance is more ex-
tensive in the mucous membrane ; if the muscular coat  has been attacked
and destroyed, we  find a smaller  ring with sharp edges, and the  ulcer
thus obtains a peculiar scarped appearance.  If, finally, the peritoneum
is perforated, this point will  occupy the centre of the  circle ;  the serous
membrane will be converted  into a yellow slough, and it will tear,  or be
voided.
   This process may run an  acute course ;  but  it is commonly chronic ;
occasionally it comes  to a standstill,  and then again  exacerbates in an
acute  or chronic form.  A cure  may result  at any of the stages, as
proved by the various cicatrices frequently observed on the inner surface
of the stomach.   Even actual  perforation of the stomach is frequently
rendered innocuous by the  adhesion of neighboring organs, and complete
cicatrization may follow.
   Loss of substance in the  mucous membrane alone is repaired  by a con-
densation of the submucous  cellular tissue into a  fibro-cellular tissue,
which causes the  edges of the mucous membrane to approach one another,
and is finally blended with it and the  muscular coat.  A radiated, aste-
roid scar, varying in size, remains.
   When the ulcerative process has  involved the muscular coat, and has
penetrated beyond it,  the muscular fibres that  edge the ulcer retract be-
yond the mucous membrane, the subserous  cellular tissue and the perito-
neum  shrivel up,  the walls  of the stomach forming the  bases of the ulcer,
and now  only consisting of these two layers,  are  doubled  inwards, the
divided portions  of the mucous membrane are thus brought together, and
a union is  gradually effected.   We then find  corded cicatrices,  which
shorten the stomach in its  transverse diameter,  or form annular contrac-
tions  proportionate to the  extent  of substance destroyed  or to  their
position.  The pylorus  is particularly liable  to  a diminution of its calibre.
   Perforation and  its temporary or  permanent  cure, demands a more
minute exposition.
   If it takes place at a portion of the stomach, which,  like the greater
part of the anterior gastric parietes, but rarely enters into a protective
adhesion with neighboring tissues, perforation  allows the contents of the
stomach  to pass freely into the peritoneal cavity,  and  fatal peritonitis
follows. 
38
ABNORMITIES OF
  This result is frequently prevented.  Whilst we  find the tolerably
uniform irritation within, giving rise to hypertrophy of the mucous mem-
brane and to callosity of the base of the ulcer and its circumference, we
see at the corresponding points of the peritoneal surface, cellular adhe-
sions, or  a  more intimate  union between the  stomach and the reverted
omentum, the left hepatic lobe, or the pancreas, produced by repeated,
circumscribed, inflammatory attacks.   The cellular adhesions which have
been effected between the stomach and the omentum,  and are sometimes
found to  unite the former with the left lobe of the liver, are not sufficient
to prevent a fatal issue when perforation occurs, for as soon as this event
has taken place, the adhesions inflame,—this,  and the forcible expulsion
of the gastric contents, loosens  and  tears  them, and thus the inflamma-
tion spreads to the peritoneum, both by  continuity of tissue,  and by
direct contact.   The perforation will be rendered  more permanently in-
nocuous by intimate adhesion, viz., by the agglutination of a fibro-carti-
laginous  exudation; as this tissue offers to the contents of the stomach,
both from  its  density and its  thickness, a sufficiently firm  resistance.
This frequently occurs between the  small curvature, or the anterior sur-
face of the stomach, and the concavity of the left  lobe of the liver, and
very frequently between the posterior gastric surface, the pancreas, and
the adjoining lymphatic glands;  but very  rarely between the posterior
surface of the stomach and the spleen,  after the latter has been dragged
into that position, or between the stomach and  the  diaphragm  (Aber-
crombie,  Chardel).   In such cases, after the external membranous layers
have been destroyed to an extent proportionate to the loss of substance,
the mucous membrane  is invariably doubled back over the edge of the
perforating ulcer, and  impinges  upon the pseudo-membranous  aggluti-
nating tissue external to  the  stomach; thus the orifice  in  the  gastric
parietes is never filled up by the superimposed tissue in such a manner
as to be flush with the  inner surface of the stomach, or even to project
beyond it into the cavity of the latter.
  In favorable but rare cases the pseudo-membranous tissue contracts
and draws  the edges of the orifices together, so  as to produce a firm,
callous cicatrix.
  In other instances this does not occur;  the  cavity,  though covered in
as described, remains, and  particularly when adjoining  the pylorus, in
consequence of the vis a tergo of the  gastric  contents, enlarges  into a
lateral sinus, which is lined by the false membrane.
  Although in the majority of cases a free opening of the stomach is
thus prevented, we may even here find exceptions ; the soldering tissue
may itself gradually be consumed, the adjoining organ is laid bare, and
becomes exposed to an extension of the process.  Thus we have seen one
case in which the adjacent diaphragm, which  had formed  a plug, was
perforated from the stomach, and the base of  the adhering lung was at-
tacked.
  In the progress  of  the  perforating gastric  ulcer  a  very important
occurrence  frequently supervenes, viz., hemorrhage, which often kills on
the first, but more  frequently after  repeated attacks.  So long  as  the
ulcer has not perforated the walls of the stomach, the  loss of blood is in-
considerable, as the process involves only the  small vessels of the mem- 
THE  STOMACH.
39
branes, which are  easily plugged up.  But as soon  as  the ulcer  has
penetrated through the gastric parietes, it meets with larger vessels in
and beyond the pseudo-membranous layer, or with the vascular system
of the obturating organ.  Thus, the trunks of the splenic, the coronary,
the pyloric, the gastro-epiploic, the  gastro-duodenal  arteries and their
branches, and more especially those going to the pancreas, are corroded
and opened, and exhausting and fatal hemorrhages ensue.
   Bloodvessels  are not alone  involved in  the  destructive process, but
other canals  also, and  we instance  the pancreatic ducts,  which, in the
case to which we allude, open upon the base of the ulcer, and by forming
pancreatic fistulae, oppose  the  complete consolidation of the imperfect
cicatrix.
   The ulcer not only proves fatal by perforation, with consequent peri-
tonitis and hemorrhage,  but also,  though rarely, by exhaustion from
dyspepsia and  harassing  cardialgia.  It is  invariably accompanied by
chronic catarrh and blennorrhoea of the gastric mucous membrane; it
heals as we have remarked, very frequently, but it as often recurs.  The
cure  of large  ulcers is  followed by considerable  deformities of  the
stomach, and more especially by shortening  of the posterior wall and the
lesser curvature, or by annular structures.  The disease  occurs chiefly
at the period of puberty, and very often,  particularly  in the female sex,
as early as the 15th year.
   The perforating gastric ulcer is in no  way  connected  with gastritis
and cancer, though it  is often mistaken  for  these affections; but it is
important to know, though  it be for the mere  cadaveric diagnosis, that
in rare cases it may be complicated with  cancer; yet it always retains
its peculiar characters  so as to be  distinguishable in the midst of the
cancerous growth  and devastation.
   (b.) Hemorrhagic  erosion of the gastric mucous  membrane.—Very
frequent opportunities are presented to us of observing loss of substance
accompanied by bleeding,  in  the mucous  membrane of  the  stomach.
There are round or roundish spots of the size of a pin's head or a pea,
or narrow,  elongated streaks, at which the mucous  membrane appears
dark red, lax, soft, bleeding, and presenting a  depression in consequence
of loss of substance or slight erosion.
   Commonly a  dirty brown coagulum is attached  to  the point, and  the
nature of the derangement only becomes evident after the coagulum  has
been  removed.   Sometimes this loss of substance involves the  entire
thickness of the mucous  membrane and the submucous cellular tissue,
and produces an appearance of small, round, or  striated ulcers.
   This process is  invariably accompanied  by hemorrhage;  the gastric
mucus,  which generally is present  in  considerable  quantity, presents
streaks of discolored blood, proportionate  to  the number of diseased
points, or it shows a  copious admixture of  brown flocculi or debris, or
we find an accumulation of fluid in  the stomach,  resembling  coffee-
grounds.  The entire mucous membrane is found in a condition of recent
or inveterate blennorrhoea and  catarrh, and in the vicinity of the ero-
sions it is often tumefied so as to form a vallated circumference.
   The number  of these erosions varies ; it not unfrequently happens that
the stomach, with the  exception of the fundus, is closely studded with 
40
ABNORMITIES OF
them, and is marked with red or brown spots, according to the color  of
the adherent coagula.
  They occur at every period of life—they are seen even in the infant,
and they are found chiefly at the pyloric portion, i. e. in that part which
is the chief seat of the catarrhal process.   The follicles, or the glandular
apparatus of the gastric mucous membrane (Cruveilhier's  gastritis folli-
culosa), appear to be their occasional nidus.
  This inflammation  and erosion undoubtedly occur sometimes  as an
idiopathic affection.  They are  more  commonly developed consequent,
or attendant upon the  most diverse,  acute, and chronic diseases, so  that
no definite conclusion as to the real  nature of the process, and  as to its
connection with other affections, has yet been arrived at.  An  acquain-
tance with the fact is of considerable importance, though  it only  serves
to assure us that the disease  is idiopathic, and  in no way allied to the
erosion produced by caustic  substances.
  3. Softening of the Stomach.—We must distinguish two primary forms
of softening, which present  essential  differences in numerous points;
both, however, are to be carefully distinguished from cadaveric softening,
the self-digestion of the stomach.
  The one, a  disease of infant  life, is called gelatinous softening.   It
appears to be a metamorphosis—a softening—of the mucous membrane
of the  fundus, which extends to the  muscular coat and  the peritoneum,
converting them and  the intervening interstitial cellular tissue,  into a
grayish or grayish-red transparent jelly, with a yellowish tinge, through
which  single dark-brown streaks, the broken-down bloodvessels, are ob-
served to pass.  Inasmuch as the softened inner strata occasionally be-
come detached, the fundus  of the stomach may be found to consist  of
nothing else but thin, gauze-like, friable portions of the peritoneum.
  The softened portion of the stomach tears at the slightest touch;  it
dissolves between the fingers, and perhaps in rare cases these rents occur
during life, but probably oftener after death, giving rise to effusion of the
gastric contents into the abdominal cavity.
  The process is  not, however, limited to the stomach, but frequently
extends to the neighboring  tissues, and chiefly to muscular organs, and
especially to the diaphragm.  Here, too, perforation is the final  result,
and with it there is effusion  of the gastric contents into the left  pleura.
  Gelatinous softening of the stomach commonly runs a subacute course:
general anaemia, which is particularly apparent throughout the intestinal
canal,  and general collapse and wasting, which are chiefly evident in the
muscular tissue, are constant accompaniments of this disease.   It is fre-
quently founded upon a demonstrable affection of the brain, principally
hypertrophy,  or hydrocephalus: and  this fact renders  it probable that
there is a similar causative nexus in those cases also, in which no visible
anomalies have been hitherto detected in the  infantine brain.   Perhaps
the proximate cause may be  looked for  in diseased innervation of the
stomach, owing to a morbid condition of the vagus, and to extreme acidi-
fication of the gastric juice.
  Nevertheless, the quaestio vexato  as to the origin  of  the  affection  in
irritation or  inflammation  remains.   If we consider, in addition to the
above  remarks,  the uniform localization of the disease, that in none of its 
THE  STOMACH.
41
stages it presents, either at the point of the softening or in its vicinity,
hyperaemia, injection, or reddening, and that we  are still less  able  to
demonstrate upon the inner surface  of the stomach, or in the tissue of
its coats, the products of inflammation, we  are constrained to infer the
non-inflammatory nature of the  affection.   This conclusion gives a key
to the various kinds of softening that occur at advanced periods of life
under similar circumstances, viz., in cerebral affections.
 _  A second form, in which softening of the stomach takes place, is dis-
tinguished by an absence of pallor in the softened tissues, or rather by
their color.  The parietes of the stomach are converted into a more  or
less  saturated dark-brown, or blackish pulp.
   It occurs under two different circumstances, though in both the process
has  an acute character,  and in both the color of the softening tissues is
produced by an alteration of the blood contained in them,  by an  acid.
They differ essentially in their genetic relations.
   In the first instance, it occurs, both in children and adults as a sequela
of acute affections of the brain and its membranes, and more especially of
tubercular meningitis at the base of the brain.  It is the same process as
gelatinous softening of  the stomach, and  the theory to which we  have
alluded is the more applicable the more fully the affection  at the base of
the  cerebrum is developed.  But the development takes place with the
greater rapidity, the less the acute disease of the brain has induced that
degree of anaemia which commonly prevails in gelatinous softening ;  and,
the  tissue being still more or less injected, the superabundant acid acting
upon the contained blood, produces the characteristic discoloration.  The
solitary fuliginous streaks above alluded to, as occurring in the pale, jelly-
like membranes of  the stomach, are analogous to  this condition. Besides,
it  not unfrequently presents itself in those cases of pulmonary paralysis
which are probably caused by a reflex action of the oesophageal and
gastric branches of the vagus.
   In the  second instance, the softening  occurs, unconnected with the
etiological relations we  have hitherto discussed, under  totally different
circumstances.  We now speak  of it as a sequela of certain cachexiae,
which were either originally acute, or  became so under the influence of
certain circumstances, viz., the exanthematic, the croupy, the typhoid in
the widest senses, pyaemia, acute tuberculosis, acute cancer—it is then to
be viewed as a fatal degeneration of these diseases. This form is developed
from a congestion in the capillary network of the gastric membranes, and
particularly of the  mucous  membrane of the fundus, which is generally
accompanied by a  more or less congested state of the  spleen.  It pro-
bably arises from the state of the blood itself which accumulates with an
excess of acid in the vascular system of the fundus, and of the spleen.
This too is the cause of  the generally rapid course of the affection, the
dark color of the softened tissues and their frequent perforation.   It
commences with a dark brown or black discoloration of the mucous mem-
brane at the fundus, which is soon converted into a black pulp that  may
easily be detached.    If  it be removed or if it separate spontaneously, a
pale, bluish-white, submucous cellular tissue is exhibited, in which ves-
sels ramify whose coats are disorganized, and which contain a black (car-
bonified) granular coagulum.   The subjacent muscular coat is pale and 
42                      ABNORMITIES  OF
thin, the peritoneum  dull, and of a dirty gray color.   The  process  ex-
tends from the mucous membrane to the subjacent tissues; they are con-
verted into a black, grumous pulp,  and thus more or less extensive per-
forations result, which are bounded by a furred margin.   Here, too,  the
diaphragm is frequently involved, and softening and perforation of this
organ follow.   The stomach is found to contain large quantities of fluid
resembling coffee-grounds or ink, which is  often vomited during life—
there is an admixture of more or  less of the softened tissues, and of their
fat, which floats in the mass  in  the shape of oil-globules.   This fluid
originates in  the  sanguineous effusion which takes place at the  com-
mencement of the disease ; the latter proceeding from the vascular sys-
tem, and first affecting  the  coats of the vessels.   On  the occurrence of
perforation, the fluid  is extravasated into the peritoneum, and  into the
left pleura ; and it here gives rise to a similar process in the serous mem-
brane, accompanied by the evolution of gas.
  In rare cases this process only takes place at  solitary, circumscribed
spots, and does not then appear to  run its course so rapidly.  The mu-
cous membrane disappears at  these points, with the exception of a very
thin, gauze-like, discolored layer, to the edges of which are  attached a
few jagged remains of the former.
  The fundus is the seat of all the softening processes  of  the stomach—
from  here they extend to the  large curvature of the stomach, in which
respect they differ from the gastric diseases that we  have already con-
sidered, or that we are about to examine, such as  catarrhs, follicular ero-
sions, the perforating ulcer, hypertrophy, cancer.   It  is  there too that
we find the perforations ; and it is only in very  rare cases  that we see
softening at the large curvature precede the development  of softening at
the fundus.
  Softening, and especially the last-named form, occurs in company with
softening of the fundus at the  oesophagus.   The lower third of this tube
is liable to be attacked, and the side which is directed towards  the left
side of the  thorax is chiefly so, as  the perforations  almost invariably
occur here,  producing effusions into  the left half  of  the thorax, after
the cellular sheath of the oesophagus  and the mediastinum  have  been
absorbed.
  The softening is never distinctly  circumscribed, but  is shaded off gra-
dually into the surrounding tissues.   It is a fact  of considerable import-
ance, that softening may take  place  after  death from  the operation  of
cadaveric, chemical changes, which  closely resemble  the processes  we
have just described.  It is not always easy to decide  between this self-
digestion and morbid  softening; nay, it is a matter of impossibility  for
the conscientious pathologist, unless he take the previous disease and the
mode of death into  consideration.
  The following circumstances may, however, serve to  characterize cada-
veric softening:
  a. The absence of all symptoms during life which indicated softening,
or the morbid processes that gave rise to it.
  b. Sudden death, from  natural or other  causes,  during the digestive
act, whilst the stomach is filled with chyme, without previous illness. 
THE* STOMACH.
43
 #  c. Limitation of the softening to the mucous membranes, and espe-
cially to the projecting folds, so as to form streaks.
   d. And at  the same time  its extension  beyond  the  ordinary boun-
daries  of morbid softening—its development being  most remarkable  at
those points at which there is a stagnation of the greatest quantity of the
gastric contents.
   4. Heterologous formation,  a. Anomalous occurrence of fatty tissue,
of lipomatous tumors between the gastric membranes, and chiefly in the
submucous cellular tissue.—These growths project into the cavity of the
stomach, being either attached  by a neck or sessile,  and being invested
by mucous membrane.   Occasionally they pass through  the fasciculi  of
the muscular coat, and present similar tumors under the peritoneum.
   b. Anomalous fibrous and fibro-cartilaginous tissue—appears chiefly in
the vicinity of the cardiac orifice and the lesser curvature, and assumes
the shape of flattish, roundish, whitish, tough concretions in the cellular
tissue, which are movable and of the size of a lentil or pea.
   c. Erectile tissue—is either  developed  at  the  free end of polypi,  or
the  mucous membrane degenerates into it on a larger surface, upon
which  the erectile tumor is attached by a broad  base, or  only by a very
short neck or stalk.   It is the common seat of encephaloid infiltration.
   d.  Tubercle and tubercular  ulceration of the stomach—are a very rare
occurrence, and primary tuberculosis of the stomach is almost unknown.
It commonly occurs as a result of intestinal tuberculosis which has ad-
vanced to an  extreme  degree;  the tubercular ulcers extend from the
ileum  through the  jejunum and duodenum into the stomach.  They
here are generally limited to the pyloric portion, but sometimes extend
to the  fundus.   The remarks we shall have to make on intestinal tubercle
apply  also to the original seat of tubercle and the character of the tuber-
cular ulcer in the stomach.  In the former the mesenteric, in the latter,
the lymphatic glands are the seat of tubercular affections, and we may
use this as  an  aid to the diagnosis of a gastric ulcer, the characters  of
which  may not otherwise be sufficiently defined.
   e. Carcinoma.—Carcinomatous diseases affect the stomach very fre-
quently, and carcinoma of the  stomach is moreover  the most  common
carcinomatous disease of the digestive tube.   It must be carefully dis-
tinguished, as we shall have occasion to explain more fully,  from mere
hypertrophy, the non-malignant thickening of the gastric membranes,
with which it is sometimes confounded.
   We  find all the different species of carcinoma, the fibrous,  the medul-
lary, the areolar, occurring at this point; though in various  degrees  of
frequency.  Fibrous cancer is the most common, the pure genuine  me-
dullary cancer less so, and the areolar variety is very rare.  Often enough
we find the  first two, and sometimes all three, occurring in primary, but
more particularly in secondary, combination.
   a. Fibrous cancer appears as  thickening  of  the  submucous cellular
stratum, which congeals into a  resisting, whitish, fibro-lardaceous mass,
and unites intimately with the  mucous and the muscular coats.   The
latter becomes pale, and gradually undergoes a change which is charac-
teristic of all kinds of cancer.   It increases in thickness,  and at the same
time degenerates into  a pale yellowish-red areolar tissue, the interstices 
44
ABNORMITIES OF
of which are filled up by a slightly translucent and apparently crystal-
line  substance.  The increase of the muscular coat is uniform, whereas
that of the submucous cellular tissue is commonly irregular, and we thus
see lobulated protuberances formed on the inner surface of the stomach.
   Fibrous cancer is the one most easily and most frequently confounded
with hypertrophy of the gastric coats.   The distinguishing signs are, the
preponderating increase of substance in the submucous cellular tissue
and  its want of uniformity, the accompanying cartilaginous hardness
and closeness of texture, the fusion with the mucous and muscular coats,
and particularly the  alteration in the muscular tissue just described (John
Miiller).
   The mucous membrane itself undergoes further peculiar  changes.   It
sometimes  degenerates into  an areolar cancerous  tissue, which dis-
charges large  quantities of a gelatinous mucous fluid; or it is  converted
into  erectile tissue,  as a fungoid  growth, which  becomes the seat  of
encephaloid infiltration, suppurates, and partially exposes the submucous
scirrhous cellular tissue;  or  lastly, it most frequently becomes the seat
of a sloe-black softening with hemorrhage, and we thus find the scirrhous
submucous  cellular tissue  invested by a  thin, gauze-like black remnant
of the mucous membrane, or it is quite denuded, merely retaining  here
and there a few solitary black convolutions of vessels at its surface.
   The scirrhus,  too,  at once becomes the seat of various metamorphoses.
It may, after it  has been denuded of its mucous membrane, become gan-
grenous in large patches or in round circumscribed spots, the tissue ex-
foliating by layers, so as to give rise to deep, smooth  excavations in the
crude cancer; or it may become developed into a more highly-organized
carcinomatous formation, such as medullary sarcoma, accompanied by
bleeding fungoid tissue; this is  soon  destroyed  by a suppurative  pro-
cess,  leaving  an ulcer which is  surrounded by an elevated lardaceous
margin.
   /5. Medullary cancer of the  stomach occurs independently of its secon-
dary appearance in  the metamorphosis of fibrous cancer, primarily  in
various forms:
   aa. In the shape of soft and even liquid, milky, medullary, infiltration
of the erectile tissue, into which the mucous membrane has  degenerated,
the other coats remaining normal (vide p. 43).
   /5/9. As a lardaceous, medullary degeneration of the submucous cellular
stratum to a greater extent.
   yy.  As knotted tumors between the gastric coats, and here too chiefly
in the submucous cellular tissue.
   Medullary carcinoma is distinguished in this form also, by its extensive
growth, and by its rapid metamorphosis, accompanied by vascular fun-
goid degeneration.
   y.  Areolar cancer presents,  in the  degeneration  of the  mucous and
submucous cellular tissues, the characters generally peculiar to  this  form.
   We often, as has been remarked,  find these varieties of  cancer occur-
ring  simultaneously ; in the stage of metamorphosis in which  more par-
ticularly a consecutive complication is seen, the fibrous cancer at the base
gives rise to an areolar cancer, from which, in its turn, medullary cancer
shoots up in the shape of a peripheral erectile growth. 
THE  STOMACH.
45
  The stomach is either the primary or the  secondary seat  of disease.
In the former, the most usual case, the cancerous  degeneration extends
from the stomach to other organs, attacking the lymphatic glands which
are contiguous to the head of the  pancreas  and  the  biliary ducts, the
pancreas itself, the glands of the lumbar plexus, and, finally  the  fibrous
investments of the vertebral column, the liver, the transverse colon, the
omentum, &c.  In the latter case, which is of much less frequent occur-
rence, the stomach is secondarily attacked, the morbid affection commenc-
ing in neighboring  tissues, and  particularly in the conglomerations of
lymphatic glands, from which it extends to circumscribed portions of its
posterior  parietes.   In this variety, the cancerous ulcer  may proceed
beyond the  stomach, establishing  communications with the transverse
colon or with other portions of the intestine, and it may even  force its
way outwards after a previous union of the stomach and the abdominal
parietes has been effected, and the latter have been destroyed.
   The pylorus, indifferently at all parts of  its circumference, is known
to be the chief seat of primary fibrous and areolar cancer of the stomach.
From this point the degeneration extends chiefly along the lesser curva-
ture over the pyloric half of the stomach ; in many, though rarer cases,
it affects the entire stomach, attacking the fundus last, which however
generally remains partially  free.   The  parietes of the stomach  may
attain an inch in thickness, being rigid  and generally tuberculated on
their inner surface ; the cavity of the stomach will at the  same time be
diminished in size.   The  cardiac orifice of the stomach is rarely the seat
of cancerous degeneration, and it is singular that cancer of the pylorus
is accurately bounded by the  pyloric ring, and  never extends to the
duodenum ;  whereas when  cancer  occurs at  the  cardia,  excepting, of
course, those cases  in  which it  descends from the oesophagus, it inva-
riably involves a portion  of the latter.
   The scirrhous pylorus is commonly bound down by the degeneration
of the tissues that lie behind  it; but exceptions occur  which  require the
more to be known, as  they materially affect the diagnosis.   The dege-
nerated pylorus may remain unattached,  and will then, owing to its in-
crease in weight, descend to a lower region of the  abdomen, even down
to the symphysis pubis, causing a hard, very movable tumor, which easily
gives rise to mistakes.
   In proportion as the  parietes increase in size and thickness, the ste-
noses of the pyloric channel will be more or less considerable;  nodose
protuberances,  uneven contraction of the tissues,  and corrugation of the
parietes, give rise  to inflections presenting  a more or less acute angle.
The greater the stenoses, and  the more the cancerous degeneration is
limited to the pylorus, the more considerable will be the dilatation of
the stomach, which  sometimes reaches an enormous size, and presents a
more or less hypertrophied state of its muscular coat.
   It is  very frequently found  to contain  the  well-known  chocolate-
colored fluid resembling coffee-grounds, the origin of which is  apparent
from the various conditions of the inner gastric surface we  have above
examined.
   Cancer of the stomach in most instances is uncomplicated, but  it is
also found coexistent with cancer of  the  liver, of the  lumbar glands, of 
46
ABNORMITIES  OF  THE
the intestine, and especially of the rectum, of the uterus, the  perito-
nium, the ovary,  &c.

  § 7. Anomalous Contents of the Stomach.—Among  the anomalous
contents  of the stomach, we class, first, the secretions  of the mucous
membrane, which, both as regards quantity and quality, in various ways
depart from their healthy condition ; secondly,  the products of different
morbid processes which occur either in the stomach or external to it;
thirdly, foreign bodies which have been introduced into it from without
in a variety of ways.
  To the first belong large collections of gas, of very acid gastric juice,
as we find occurring in chronic gastritis and many other morbid meta-
morphoses of the gastric  membranes, the absence, but more frequently
the excess, of a white, milky, opaque, and purulent, or of a transparent,
viscid, gelatinous, glassy mucus, such as we find in chronic catarrhs, or
in a blennorrhoic condition of the gastric mucous membrane.
  To the second belong the products of exudative processes, and of
ulcers  in  the  stomach itself, such as plastic, viscid mucous,  fibrinous
exudation, pus, ichor.  The latter may also be introduced from without,
from abscesses  of contiguous organs, the liver, the spleen, the pancreas,
the lymphatic glands, from ulcers of the oesophagus, and even from ab-
scesses of the vertebras.
  Blood  occurs in varying quantities; when found to a large amount
either  in a coagulated or fluid condition, it commonly has  its  source in
rupture of varicose veins of the oesophagus or stomach, in rupture of an
aneurism communicating with those  cavities, or in corrosion of arteries
lying at the base of a  perforating gastric or duodenal  ulcer.  Occa-
sionally, too, the capillary bleedings which accompanying  follicular in-
flammation and erosion, degenerate into such exhausting hemorrhages.
  Blood  may also occur as a reddish-brown, or black pulverulent  sub-
stance, either mixed up with the contents of the stomach, and especially
with the mucous secretion, in the shape of streaks or flocculi, or attached
to the  mucous membrane, and more especially to the bleeding portions.
  Or it  may  occur as a  chocolate-colored, coffee-ground-like  or inky
matter, and that will be the case under  all circumstances  that  give rise
to gastric hemorrhage, if the blood has been retained in the stomach for
a certain period, and submitted to the action of the gastric juice.  It is
evident that this will chiefly be  the case in passive hemorrhages.  We
gather from the preceding observations that the following  are the cases
in which the contents of  the stomach  present  this  appearance, and in
which there will be vomiting of black matter during life:
  a. In slow hemorrhage from a perforating ulcer of the stomach ;
  b.  In capillary hemorrhage accompanying hemorrhagic erosion of the
gastric mucous  membrane and their follicles ;
  c.  In softening;
  d. In the hemorrhages that accompany cancer of the stomach.
  In rare cases we find blood in the  stomach without being able to trace
a distinct cause  of the hemorrhage, either in or out of the organ ; the
parietes of the stomach  are either found  to be  in  a state of  complete
anaemia,  or occasionally  single,  red, injected  portions  of the mucous 
INTESTINAL CANAL.
47
membrane are visible, which bleed on the application of slight pressure
from below, by which the congestion is increased.  There is no doubt
that, in such cases, hyperaemiae of various kinds precede, and blood at
once transudes through  the vascular coats;  the greater  the impulse of
the blood,  the laxer the tissue and the vascular coats, and the  thinner
the blood itself is, the easier will this be brought about.
   The blood which is found in the  stomach is not only, as we have re-
marked, frequently the  result of extravasation which has taken place
external to the stomach, but it may even  have been  extravasated ex-
ternal to the oesophagus and  intestinal canal.   Thus  it is often swal-
lowed in large quantities during hemorrhages of the respiratory  mucous
membrane.
   Finally, there  may be bile, biliary calculi, fecal matter, and lumbrici,
in the stomach.
   To the third class belong the most various foreign bodies which have
been swallowed accidentally, or in consequence  of morbid appetites ; in
the latter  case, chiefly seen in lunatics, they are taken  in large quan-
tities, and with evident  selection.  We may enumerate flints, clay, in-
digestible vegetables, grass, and straw, waste pieces of clothing; metallic
substances, as coins, bullets,  iron nails, pins,  &c.   They give  rise to
various lesions, to perforation  of the stomach,  or at least, to irritation
and inflammation, with subsequent ulceration of the mucous membrane.

          SECT. V.—ABNORMITIES  OF THE INTESTINAL  CANAL.

   § 1.  Befective and excessive Formation.—A  complete  absence of the
intestinal  canal when an abdominal  cavity existed, has probably never
been observed.   It is frequently defective;  at  times it is a short  tube
of uniform calibre, attached to a flat  narrow strip of mesentery, or  it
consists of several detached portions of intestine which are strung toge-
ther on a very defective fold of the peritoneum.
   We must here  mention the  blind termination of the intestine at dif-
ferent points of its course, there being  either a fresh  acuminated com-
mencement lower down, or an  absence  of the  remaining portion.   The
most frequent anomaly  is the more  or less extensive  deficiency of the
rectum  with  a consequent atresia  ani.   The latter abnormities demand
the formation of an  artificial  anus  at  the natural situation, or at some
other suitable part, if they occur in individuals who are otherwise  capable
of sustaining life.
   Defective formation may occur in the shape of tissue, of irregular com-
munication of the intestinal tube, as in the case  of the latter discharging
at  the  navel, into the  cavity of the  urinary or small sexual  organs
(cloaca); it then is commonly the result of an arrest of development.
   Excess of development, with the exception of the various  degrees of
biventral monstrosities, is probably nothing but  a deceptive appearance;
the repetition of some of its  segments, and the presence of larger or
smaller blind appendices, which open outwards or into the intestine, and
more especially  the  so-called  diverticula, are  almost  invariably to be
considered as arrests of formation.
   The  latter, the congenital diverticula, Meckel's diverticulum  verum, 
48
ABNORMITIES OF THE
deserve a special consideration.   It is a dilatation of the small intestine,
representing a  hollow  appendix, which  consists  of  all the  intestinal
membranes, and is placed at from eighteen to twenty-four inches from
the caecal valve ; although we do not quite assent to Meckel's view, that
it  is a remnant of the  umbilical canal, it evidently has its origin in the
development of the intestine  in  the umbilical  vesicle.  We accordingly
always find it solitary  and attached at  the above-mentioned spot;  it
varies  in length from five to  six inches; it sometimes is wider, some-
times narrower,  than  the intestine itself; it is frequently contracted  at
intervals, of a conical or cylindrical shape, and terminating in a round,
clubbed, or lobulated expansion.   It either projects at right angles from
the convex surface of the intestine, hanging unattached in the  abdomen,
or it passes off at an acute angle from the concave surface of  the intes-
tine near the mesenteric insertion, being attached to the latter by a falci-
form process of  the peritoneum.   In this case  it is often  placed parallel
to the intestine.  Occasionally a ligamentous  cord, the remains of the
omphalo-meseraic vessels, is found at its free extremity, and as  this may,
by its adhesion  to various points of the peritoneal cavity,  give rise  to
internal  hernia (strangulation of the intestine), it receives importance  in
a pathognomonic point  of view.
   The following case, in which this appendix  was abortive, may be in-
teresting : In the corpse of a young man, the small intestine was found
enlarged  at the above-mentioned spot,  to the extent of  several inches,
the peritoneum and the adjoining laminae of the  mesentery were white
and opaque, studded with  tendinous patches, and  a tolerably  long liga-
mentous cord, the remains of the bloodvessels, was found depending from
a rounded embossed dilatation.
   We may finally observe that  the entire intestinal canal or portions  of
it, are found in  some individuals inordinately long or short; no fixed
rule has, however, been established with  regard to the relation among
the parts themselves, to the stomach, the organs of mastication, &c.

   § 2. Abnormities of  Size.—The congenital malformations  belonging
to this section, are the  anomalies which we have described above, when
speaking of the length of the intestine, and the true diverticulum.
   The acquired malformations, as distinguished from the former, have
reference to the calibre of the intestine, and  are either dilatations  or
contractions.
   The former occur either as uniform dilatations of the tube, or a lateral
extension.
   Uniform  dilatation is the  result of atony, or  paralysis, consequent
upon  concussion,  habitual repletion,  peritonitis,  rheumatism,  typhus,
dysentery, cholera, overstimulation by injections and purgatives, and the
like ;  or it is the immediate  consequence of disease in the  nervous cen-
tres ;  or the dilatations  may  be developed  as dilatations of  an active
character, i. e. with hypertrophy of the muscular coat above  a constric-
tion.   In accordance with their  etiological relations, they occur chiefly
in the colon.
   The lateral dilatation of the intestine occurs  in a form  resembling a
diverticulum, constituting  the  false, in contradistinction to the true  di- 
                       INTESTINAL  CANAL.                     49

verticulum; it is a hernia of the intestinal mucous membrane, resulting
from the separation of the fibres of the muscular  coat.  It differs in
every one of its  characters from the true diverticulum :
  1st. False diverticula consist solely of mucous membrane  and perito-
neum ;
  2d. They occur at the duodenum, in the entire course of the small and
large intestines;
  3d. They are found in considerable numbers;
  4th. They occur from the  size of a pea to that of a walnut, in the
shape of round,  baggy pouches of the mucous membrane ;
  5th. They  form,  more  especially in the colon, nipple-shaped appen-
dages, which occasionally are grouped together in bunches ; when occur-
ring in the small intestine, they are commonly developed on its concave
side,  and are  therefore placed between the layers of the peritoneum;
when in the colon, the faeces are retained by them, and dry up into stony
concretions.
  Contraction of  the calibre of the intestine  at a small  portion, or in a
greater extent,  is the effect of the  pressure or traction exerted by  large
morbid  growths, by hypertrophied  contiguous organs, the impregnated
uterus, uterine  fibroid tumors, dropsy or cancerous degeneration of the
ovary, &c.; it is brought on by incarceration or traction of the intestine
in external and  internal herniae, by invagination,  by adhesion of the in-
testine, accompanied by angular inflection at the point of adhesion ; by
compression of  a  large portion of intestine  into a small space, in conse-
quence of a firm adhesions between the coats and the peritoneum;  it is
produced by disease of the tissues, and  more especially by cancer  (can-
cerous stricture), by cicatrization of tubercular ulcers, by the healing of
loss of substance in dysentery, by catarrhal suppuration, by the scar fol-
lowing a gangrenous slough, or  by simple  hypertrophy.  The passage
of the intestine is moreover interfered with or entirely obstructed, by
tumors  which project  into the  intestinal  cavity, and  it  is  variously
affected by foreign bodies.
  We have lastly to remark, that  we find  various states of contraction
and vacuity of the intestine coexistent with its blind termination,  with
an artificial anus, or with stricture.
  In a  different  point of view we must here cite the anomalies which
occur in  the  dimensions of the  intestinal parietes: they appear in the
shape of augmentation or diminution,  i. e.  thickening or  thinning.
Thickening is found to accompany or result from textural diseases, under
which head this form  will be considered; but it  also presents itself as
simple hypertrophy.
   This either affects the mucous membrane and the muscular coat  sepa-
rately, or both  simultaneously, together with the  intervening cellular
tissue.   In  the  first and last cases it is  the  result  of a repeated and
habitual state of irritation  of the intestinal mucous membrane, which, in
accordance  with  a uniform law, after a certain  duration gives rise to
hypertrophy  of the  muscular coat, and an  increase in  the density and
quantity  of  the intervening  cellular layer.   The hypertrophy of the
mucous  membrane is presented to us in a  very characteristic shape in
polypus  of the intestine ; this growth is peculiar to the colon, and chiefly
  VOL. II.                            4 
50
ABNORMITIES OF THE
to its terminal portion, being often remarkable for its length, its frequent
repetition, and the massive cauliflower-like development of its free ex-
tremity.  When  hypertrophy exclusively or mainly affects the muscular
coat, it generally results from  excessive innervation  accompanying
habitual spasm of the intestine, or from extreme excitement of its mus-
cular activity induced  by repeated or continual repletion,  as  we  see
following a stricture.
   Excessive thinning of the intestinal mucous membrane,  presenting an
appearance which resembles that of serous membranes, occurs chiefly in
the colon after the protracted  serous  diarrhoeas  which accompany con-
sumptive diseases ; the tissues  are there found in an anaemic  and pallid
condition, without exhibiting any conspicuous anomaly in consistency.
   Atrophy of the muscular and mucous  coats of the intestine is often
seen in connection with tabes universalis, though rarely as it appears,
dependent upon idiopathic torpor of the abdominal ganglia ;  it is found
coexistent with a wasting of the mesenteric glands in  hypochondriac and
melancholic affections, or as a signal  of certain  acute processes, as  for
instance, of typhus, or as a consequence of slow poisoning  by lead. The
thinning which, coupled with  relaxation and friability of  the  intestinal
membranes, occasionally exists simultaneously with  an accumulation of
fat in the mesenteries and  omentum, is still more remarkable.  The  ex-
cessive  production of fecal matter (copropoesis excedens) which fre-
quently accompanies these two conditions, is important in reference to
their pathogeny.
   The follicular apparatus  frequently becomes atrophied at an advanced
age, but it may be similarly affected  in consequence of acute diseases,
such as ileo-typhus.  Berres has demonstrated senile atrophy in the in-
testinal villi.

   §  3.  Beviations of Position.—The  intestinal  canal may be irregular
in position, either being placed altogether external to the  abdominal
cavity, or by its  relations  and its disposition  within the cavity being
irregular.
   In the first class we reckon the following congenital irregularities:
protrusion  of  the intestines, external  to the abdomen, from absence of
the parietes, or from fissure at or near the median line (eventration,
omphalocele, congenital umbilical hernia);  congenital inguinal hernia;
thoracic hernia from partial or total absence of the diaphragm, the left
side of the latter being  chiefly liable to this  malformation.  To the
acquired irregularities  belong  prolapsus of the intestines, resulting from
penetrating wounds of the abdomen, wounds or rupture of the diaphragm,
and the different forms of ordinary hernia.
   In the second class we reckon, as a congenital deviation, the lateral
transposition which is likely at the same tim e to involve secondarily, not
only the other abdominal,  but also  the  thoracic viscera; the  various
changes of position, produced  by diffused or circumscribed  fluid effusions
or accumulations,  by hypertrophied viscera, or by morbid  growths ; the
spontaneous descent of the transverse  colon into the hypogastric region,
of the small intestine into  the pelvic cavity;  external and so-called in-
ternal hernia; invagination and prolapsus ani, the two being identical in 
INTESTINAL  CANAL.
51
character and causation;  the changes of position which the intestine ex-
periences in  consequence of the cellular or fibro-cellular adhesions that
it forms with the parietes, and that unite the coils to one another.
  For external hernia we refer  the reader to surgical works;  we shall
here examine only the relations of internal hernia, invagination, prolap-
sus ani, and the change of  position produced in the  intestines by adhe-
sion.
  1.  Internal hernia.1—We  define internal hernia, in contradistinction
to external hernia, as  a change  of position in the intestine leading to in-
carceration, which occurs in the  abdominal cavity without the formation
of a hernial sac, and which is therefore not accessible to the usual mode
of examination applicable to external hernia.  Certain cases in which the
intestine is placed or incarcerated in congenital folds or pouches of the
peritoneum, such as we occasionally see  in the hypogastric region, are to
be viewed as transition forms between internal  and external hernia (vid.
Peritoneum,  p. 24).   The former are also  termed incarceratio,  strangu-
latio  interna.
   They may be subdivided in the following manner:
   a.  Incarceration is  the result of the simple pressure, which is exerted
upon one or more points of the intestinal tube, by a portion of the intes-
tine  or by the mesentery,  resting upon the former.  It  is a matter of
course that this simple compression of a  portion of the intestine, can only
be effected in the direction of the resisting posterior walls of the abdomen,
and at its lower segment; inasmuch as  the occurrence of a similar  rela-
tion anteriorly is inconceivable, on account of the smoothness and yielding
nature of the parts.  Experience confirms the fact that the small intestine,
from  repletion or increase of volume, is  particularly prone to occupy ab-
normal positions; it is very liable to descend, and  with its lengthy and
frequently hypertrophied mesentery, fall and weigh upon the colon or the
rectum, and  to compress  their walls.
   These incarcerations of the intestine  commonly occur at an advanced
age,  at which a descent of  the intestines to a lower  region of the abdo-
men  and  into the pelvic cavity,  prolapsus of the pelvic viscera and large
herniae, which may be viewed as analogous conditions, are very frequent.
  A  long, flabby mesentery predisposes  to the complaint; especially
when, by traction, it has  been converted into a pedicle or cord.   Beple-
tion  of the intestine  above a stricture, accompanied by atony,  or the
dislocation of the intestine in large herniae (inguinal and scrotal herniae),
is likely to produce  this effect.
   b.  Incarceration may be  the consequence of a rotatory movement, and
of this there are three varieties:
   a.  A portion of intestine may have become twisted upon its own  axis,
and we then find that  even semi-rotation causes such an approximation
of its parietes, that  they touch and close up the passage.   This can pro-
bably only occur in  the colon, and according to the cases on record, only
in the colon ascendens.  Accumulations of gas, and unequal filling of
different portions of the intestine, appear,  as far as  we are able to judge
from  the  few cases which have been  noticed, to be  the cause.   Such an
1 Vide Oestr. Jahrb. x. 4. 
52
ABNORMITIES  OF THE
occurrence is scarcely conceivable in the small intestine, on  account of
the uniformity of its calibre, the absence of angular flexures, and its loose
position, as every rotation of one  portion upon its axis would be counter-
balanced by the rotation of the next segment.
  (3. The mesentery may be the axis, and the intestine will then be rolled
up  upon the former, i.  e., the entire  mesentery,  or  a  portion  of it, is
twisted into a cone, and in proportion to the number  of its rotations,
more or  less of  the intestine  will be dragged after it.   In this case we
must take into consideration the traction and the pressure, which the in-
testine suffers at the acute angle, which  the  dependent mesenteric cone
forms with the base  whence its point  rises.  This variety can  scarcely
occur anywhere but in the small intestine and its mesentery.
  y. One portion of the intestine, either single  or double—a coil—may
afford the axis round which another portion with its mesentery is thrown,
so as to be throughout in contact  with  the  circumference of the axis, and
thus to compress  it like a ferrule.   This variety is  evidently a higher
degree of the first  in which a portion of intestine is  merely compressed
from before backwards, and,  as it were, flattened down.  A coil of small
intestine, the sigmoid flexure, or  the caecum, may form  the axis.
  The last two varieties occur like the first, chiefly  at  an advanced period
of life.   In early life a predisposition to the affection may be caused by
a congenital malformation of the  mesentery, by  large herniae, or by small
herniae when there is adhesion of the intestine.
  This predisposition  consists, first, as in  the incarcerations of the first
variety—in a congenital or acquired long, loose, and flabby mesentery,
by which a rotation of the intestine round the mesentery or another por-
tion of intestine is rendered  possible; and secondly, in an  enlargement
of the  abdominal, and especially  of the pelvic, cavity.
  c. The incarceration of the intestine may be effected by peculiar struc-
tures, which  either belong to  the normal condition, or are  congenital
malformations, or  are, in part at least, the products  of previous morbid
processes.   We allude to genuine incarcerations of the  intestine in vari-
ous annular spaces or fissures, of which we cite the following:
   a. The fissure of Winslow, in which we  once  found a large portion of
small intestine strangulated;
   /9. An intestinal  diverticulum (verum), which is  directly or indirectly,
by means of an obsolete vascular cord, attached to a certain portion of
the peritoneum;
   y. Adhesions of the free end of the caecum,  or of  the vermiform pro-
cess;
   d. Holes or fissures (congenital or acquired) in the  mesentery ;
   e. Malformations of  the omentum, forming rounded or flattened cords
and bands which are attached to  the peritoneum, or  furcated fissures of
the  omentum;
   Z. Pseudo-membranous formations, as  the result of previous exudative
processes, in the shape of cellular or ligamentous cords,  bands, or plates,
which pass from one part of the intestine  or the mesentery to  another,
from the  intestine to the abdominal parietes, the  omentum or an organ
of the abdominal and pelvic cavity, or  from one of these to the abdominal
parietes, or between the organs themselves. 
INTESTINAL CANAL.
53
  It is most frequently a portion of the small intestine which  is incar-
cerated in these structures; only the more movable portions of the colon,
the caecum and the sigmoid  flexure,  are likely to become involved.
  These varieties of  incarceration are very common, and, as compared
with the others, the most frequent.
  They occur at every period of life.   The female sex is more prone to
them than the male, as the omentum, the diverticula that may be present,
and pseudo-membranous formations, are not only frequently attached to
the internal  sexual organs of the female,  but the latter  are themselves
liable to  give rise to new growths.
  The consequence of internal hernia is a distension of the intestine above
the compressed or strangulated portion, peritoneal inflammation, para-
lysis, and ileus;  the  incarcerated portion in hernia of the third variety
is from the strangulation of its mesenteric vessels peculiarly liable to con-
gestion and gangrene.
  This affection, when diagnosed, most imperatively requires an opera-
tive proceeding, for the purpose of disentangling and arranging the in-
testines,  and for  division of the strangulating structures with or without
the knife.
  2.  Invagination of the Intestine.—Invagination or intussusception,1
incorrectly termed volvulus, consists in the inversion  of a portion of in-
testine into the cavity of the adjoining upper or lower portion.
  We frequently find intussusception in the corpses of children and
adults, but in the majority of these cases it is produced during the last
moments of life,  during the death-struggle. It is the result of an unequal
irritability of the intestine, and the consequent irregularity of  its move-
ments, and it is therefore frequent in diseases characterized by  torpor of
the cerebro-spinal system, and in the mortal agony proceeding from them ;
whereas it rarely or never occurs in diseases accompanied by, or ending
with, abdominal paralysis such as cholera, typhus, general peritonitis, &c.
In this case we find no traces of reaction, the parts are easily restored to
their proper  relations, the inversions are found occurring simultaneously
at several points, though only in  the  small  intestine, and the  inversion
may take place downwards, and at the same time, but rarely, upwards.
  Another form  of invagination, which, once formed, presents  itself as
an idiopathic, dangerous,  and often fatal disease of the intestinal  tube,
is of extreme  importance, and  will be  the subject of  the  following
remarks.
  Every intussusception consists of three  layers of intestine:  of these,
reckoning  from  without  inwards, the  first and second  present  their
mucous, the second and third  their peritoneal, surfaces to one another.
The canal of the intussusception or volvulus passes  through the latter.
In  order to facilitate comprehension, and in accordance with fact, we
term the external layer of the intestine the  sheath of the  volvulus, or
the intussuscipient portion, the innermost layer  the  entering  tube, the
middle one the receding or inverted tube,  and the  last  two  together,
the intussuscepted portion, or the volvulus  properly so-called. It follows
that isonomic layers  are always  opposed to one another; and we shall
1 Oestr. Jahrb. xiv. 4. 
54
ABNORMITIES OF THE
find  this to be the case  even when the  intussusception is  double, and
consists of five superimposed layers.
  Between the entering and inverted tube we  find a portion of mesen-
tery, of corresponding  size,  and of an arcuate form.   It is folded up
so as to represent a cone, the apex of which lies at the free termination
of the volvulus, with  its base in the sheath, and at the entrance to the
invagination.
  This  portion  of mesentery is always  in a  state of  tension, which
chiefly affects the part  belonging  to  the inverted  tube, and has a sin-
gular influence upon  the form  of  the volvulus.  It is the cause of  the
following circumstances:
  Firstly; that the volvulus does not lie parallel to its sheath but always
offers a greater  curvature than  the latter, the inverted tube being com-
pressed in its concavity into  tense transverse folds.
   Secondly; that the orifice of the volvulus does not lie in the axis or
in the centre of the sheath, but  external to it; and that, following  the
traction exerted upon  it by the  mesenteric fold  that  belongs to  the
inverted intestine, it  is directed  towards the mesenteric  wall of  the
sheath; that it is not circular, but  represents a fissure.   This affords  a
diagnostic  sign  for the  examination of intussusceptions of the rectum,
which are within the reach of manual exploration.
  Intussusceptions occur with  equal  frequency in  the colon and  small
intestine; but  several cases  which have  been described as occurring in
the former are remarkable on account of the magnitude  they attained.
In these cases the sheath contains  a very long portion of the colon and
ileum ;  both  may be inverted two or three times, and the intussuscepted
part advances to the vicinity of the anus.
   An  inversion  of the  intestine from  above  downwards is  the  most
usual occurrence.   Post-mortem  examinations have, with very rare
exceptions, proved this to be the case;  and it is but fair to assume  the
same in those cases in which, after urgent symptoms of danger, larger
or smaller portions of intestine  were discharged, and the patients  reco-
vered.
   We naturally ask how the intussusception is brought  about, and how
its enlargement is effected ?
   The cause is to be found either in the contraction and movability of
a piece of the intestine, on  which account it passes into the  adjoining
and more  capacious tube; or in the extreme expansion or relaxation of
a segment of intestine, which gives rise to an inversion of the adjoining
narrower and  more innervated  portion.   In every case the volvulus is
formed at the expense of the external layer of the  intestine or sheath.
For we find  that the  entering  portion, as it enters and advances  (in-
crease of the volvulus), is not  reverted at its free  termination to form
the  receding tube, but that the latter is formed by the inversion of  the
sheath at the entrance of the volvulus.1
   Whether the intussusception  takes  place in one way or the other, the
volvulus is not  immediately subjected, as is commonly thought, to  an-

  1 [In other words, the volvulus  increases at the expense of the inferior portion of the
intestine.—Ed.] 
INTESTINAL CANAL.
55
nular strangulation.  In the first instance, the mesentery of the volvulus
and its vessels suffer tension and compression at their entrance into the
sheath;  and, in consequence, we have in the volvulus an obstruction to
the  circulation, with  swelling  and  intense  redness, in short, violent
inflammation, which  gives  rise to sero-sanguineous infiltration of the
tissues, plastic effusion on the contiguous serous surfaces of the entering
and receding tube,  and upon the mucous membrane of the latter.  The
inverted  portion is invariably the one that  suffers  most; the inflamma-
tion  of the  entering  tube is  less considerable, and it is characteristic,
that even when the inflammation of the volvulus runs high, its mucous
membrane remains pale; the sheath  of the volvulus also is but slightly
affected in small intussusceptions, with the exception of the peritonitis
at the point where it enters.   In large  invaginations of the  intestine,
however, the sheath is more deeply involved in the inflammatory affec-
tion  on account of the tension of the  mesentery and the strangulation of
the vessels.
  In consequence  of the  tumefaction that results from the inflammation
of the volvulus, we find, as a secondary occurrence, the  formation of a
true annular incarceration, either at the entrance, or in rare cases, at
other points.
  During this period, in which  the  volvulus  becomes fixed,  in conse-
quence of the tumefaction, the incarceration, and even the  adhesion of
the contiguous serous surfaces, which is brought about by plastic exuda-
tion, it gradually or periodically enlarges to  an enormous extent; the
peristaltic action, and the increased  accumulation of the  intestinal con-
tents, forcing the volvulus, the sheath of which continues to  be progres-
sively inverted, lower down.  We are thus led to distinguish  between a
primary  and a consecutive form.
  If  the intussusception does not prove fatal by the peritonitis which
extends upwards from the serous  surfaces of the entering and receding
tube, with symptoms of  strangulation, or by gangrene of the volvulus,
it may have other  more or less favorable terminations.
  a. The most favorable issue,' although purchased at the greatest risk
of life, is gangrene and  discharge of the  volvulus and  its mesenteric
portion, subsequent to a complete  adhesion between  the entering and
receding tube at the entrance into the sheath.  At the  spot where the
separation  has taken  place, we find, in  the corpses of individuals who
had  been thus  affected,  an annular  swelling, which more or less inter-
feres with the calibre of the intestine, and adhesions with the contiguous
peritoneal surface, and more particularly of the mesentery.
  b. In rare cases, in which the  incarceration has  been developed at an
unusual point, only a partial  sloughing of the volvulus takes place, and
the portion which lies above the strangulation is retained.  Under these
circumstances, the  latter forms a conical plug with a narrow  channel,
and  projects into the cavity of its  sheath, surrounded by a thick fringe
of mucous membrane.
  c.  Occasionally  the inflammatory action which has taken place in the
volvulus abates,  after having  caused  adhesion between the entering and
receding tube, and the volvulus is retained.
  The process described under a,  generally leaves a sufficient passage, 
56
ABNORMITIES  OF THE
and consequently ends in a permanent cure, which cannot be predicated
of  the  other  two events.  In the  latter, a chronic state of hyperaemia
and inflammatory intumescence remain, with a liability to exacerbations.
General intestinal inflammation not unfrequently follows.   The channel
of  the intestine does not suffice for the removal of its contents, and the
volvulus, or the remainder of  the volvulus, arc moreover the cause of a
consecutive increase of the intussusception.
   Invaginations occur at all ages.   Diarrhoea is the chief predisposing
cause, and the most  rational  therapeutic proceeding consists, according
as  the inversion  has taken  place  upwards or  downwards, in an early
injection or exhaustion of air by means of a syringe.   To be effective,
this must be done before the volvulus has formed adhesions.
  Intussusception has an .analogue in prolapsus ani.
  3. Prolapsus ani.—Prolapsus ani is a volvulus  without a sheath, and
it is characterized by an inversion of the internal  portion of the intes-
tinal tubing.  It represents a sausage-shaped or pyriform tumor, which
is contracted at the anus, so as to form a pedicle,  and at the free  extre-
mity there is,  in trifling cases, a round central opening, which in larger
prolapsus assumes  an eccentric position, and,  following the  traction
exerted  upon  it  by the  mesorectum, recedes so as to present a mere
fissure.   The external mucous layer is the  seat  of inflammation  and
swelling, which partly proceeds from mechanical hyperaemia, partly from
irritation produced by the atmosphere.  It is the result of  violent and
lasting diarrhoea in children,  or of blennorrhoea of the rectum in adults
and old  people.
  4. Altered position of the intestine consequent upon adhesions.—These
changes of position1  vary according to the point of adhesion, and assume
very different  forms.  They are of importance, as they sometimes offer
impediments to the propulsion of the contents of the intestine; but this
is not in a ratio with the extent or degree of adhesion, but  bears a direct
relation to the degree of dislocation produced in one  or  more coils  of
intestine.   We are now alluding to the adhesions produced by cellular
or fibro-cellular tissue, -the remains  of an entirely extinct exudative pro-
cess, since we find that similar adhesions, when accompanied by hetero-
logous formations, and especially by peritoneal  tuberculosis, rarely pro-
duce constipation, but almost invariably give rise to diarrhoea.
   We therefore speak of the following forms :
   a.  Partial circumscribed adhesions of the intestine, with the abdominal
parietes, with a second, less  movable portion of the tube, with the me-
sentery, with  the internal-female sexual organs, &c, causing an angular
inflection of the intestine.  The inflection will be the more considerable,
the more the adhesion is limited, and the more remote the  latter is from
the normal position of the intestine.
   When occurring at the colon, the dislocation may be induced by direct
adhesions of the less attached portions, or indirectly by the adhesions of
the omentum, especially when the latter is shortened, or when  it lies  in
the sac  of an inguinal or femoral hernia.
   b. Extensive adhesions among the coils or the mesenteries, that often
affect the entire small intestine, in such a manner as to twist and bend
1 Oestr. Jahrb. xviii. 1. 
INTESTINAL CANAL.
57
them, and  to produce external valvular duplicatures of the  intestinal
coats at the  projecting  angles.  This  form of adhesion is not  unfre-
quently developed in intestinal segments which have long been included
in large hernial sacs, in which case it is limited in extent.  A remarkable
instance of this was offered in a case of fatal constipation, where a por-
tion of the ileum, twenty-four inches in  length, was found inclosed in a
cartilaginous sheath of peritoneum of four inches.

   § 4.  Solutions of  Continuity.—These are the  effect of  penetrating
injuries produced by cutting instruments or firearms, or they may be  the
result of concussions affecting the entire trunk, as in the case of a  fall
from a considerable height, or a small portion of  the abdomen only, as
from compression, in being  driven  over, &c, in  either instance  giving
rise to rupture or laceration of the intestine; or they may be the conse-
quence of ulcerative processes that proceed  from without inwards, or vice
versd, in the shape of perforating intestinal ulcer.
   The danger of these lesions bears a direct relation to their extent, and
in the last case, also to  the  rapidity with which the morbid  state is
developed.
   We must finally adduce those perforations of the intestine which  are
the  combined result of  mechanical injury,  and  of an ulcerative process
brought on by foreign bodies that have  been introduced into the canal;
the putrefaction of the intestine, in consequence of sloughing gangrene
at or near the spot;  and the spontaneous and incurable ruptures of  the
intestine which follow its excessive distension above a stricture, and  are
commonly accompanied by circumscribed sloughing of the mucous mem-
brane, or which are the consequence of complete ^oftening of the coats.
   Unless  the  injury affects the coats of the intestine in a very slanting
direction, we find that in wounds produced by cutting or stabbing, slough-
ing or  ulceration, the mucous membrane projects over the peritoneal sur-
face in the shape of a tumid fold.   In the case of ulcerative  perforation,
this will not take place until the destruction of the external and internal
plates coincide.
   In those cases  in which a fatal termination is not induced by an escape
of fecal matter into the  abdominal cavity, giving  rise to general  perito-
nitis, nature adopts the following process :
   After a  mechanical injury has been inflicted, we find  that in the vici-
nity of the orifice, plastic  exudation immediately agglutinates the perfo-
rated coil to an adjoining surface, which temporarily closes up the hole;
in ulcerative processes the perforation  is  generally anticipated  by  the
inflammatory action of the peritoneum throwing out a guard of lymph.
   This agglutination, when following injuries to the intestines that occupy
the umbilical region, rarely unites them with the abdominal  parietes, ex-
cept by the intervention of the omentum, which protrudes into the open-
ing of the abdominal walls; it commonly unites them to a  neighboring
coil.  The small  intestine that  lies in the  inguinal  region,  the colon, a
portion of intestine included in a hernial sac, are in close  proximity to
parietal regions  allowing  agglutination, and we  there  find the  lymph
converted into cellular tissue.
   The opening in the intestine  communicates with the external  surface 
58
ABNORMITIES  OF  THE
of the body by means of the agglutinating medium.  After ulcerative or
gangrenous perforation has occurred, the extravasated intestinal contents
give rise to and maintain inflammation and  ulceration; and thus per-
foration  of the abdominal parietes or of  the adjoining intestinal coil is
induced.  In the first two cases an abnormal opening of the intestine out-
wards is formed, which, according to its size, and in proportion as it suffices
for the discharge of feculent matter, receives the name of fistula sterco-
ralis or anus artificialis.  In the latter case an abnormal communication
is  established  between two portions of intestine (fistula bimucosa), and
then we have a condition which presents a variety of complications.
   These  results may not take place ;  the minute  intestinal orifice which
results from ulcerative or gangrenous perforations, not sufficing to induce
the secondary destruction of the adjoining abdominal or intestinal pa-
rietes, the agglutinating tissue is converted  into a rounded extended cord,
into which  the perforated intestine sends a funnel-shaped prolongation of
its mucous membrane, and the intestine itself is thus less firmly attached.
Continued  traction gradually closes up this funnel-shaped cavity, the cord
becomes  solid, and  the  mucous  membrane cicatrizes over it, generally
leaving a pouch at the spot.   At a later period the cord may become
detached, and it then shrivels up into a cellulo-fibrous nodule lying  above
the cicatrix of the mucous membrane.
   The cure of fistula stercoralis is established in a similar manner.   The
intestinal opening communicates by means of a layer of organized lymph,
with the  external surface of the abdomen.   The exudation gradually be-
comes distended so as to form a hollow cord, which, to a certain extent,
is lined by  the mucous membrane of  the perforated intestine; continued
traction  lengthens out the cord, its channel diminishes at the same time
and finally closes.   The immediate consequence is the  healing up of the
external  fistulous opening, and  in the same manner cicatrization of the
intestinal orifice may be effected.

   § 5.  Biseases of the  Tissues.—The muscular coat  is scarcely ever
proved (by cadaveric examination), to be primarily affected;  the disease
almost invariably arises in the mucous and the submucous cellular tissue,
and involves the former secondarily; Ave are, therefore, the more limited
to a consideration of the affections of the mucous and the submucous cel-
lular tissues, as they demand a minute investigation on account of  their
extreme  importance.
   We may infer the general importance of this branch of pathology from
the rank the mucous membrane occupies in the  domestic economy, from
the consequent frequency, and the variety in  the  forms of its idiopathic
affections, but more especially from the frequency of the secondary com-
plications to which  it is subject, from the numerous relations which it
bears to  other systems and organs, and the fluids at large.
   We introduce the subject of inflammation by a preliminary considera-
tion of the hyperaemic and anaemic states of the mucous membrane.
   1. Hyperaemia,  Anaemia.—a.  Hyperaemia is the result of active con-
gestion,  arising from idiopathic, sympathetic, or metastatic irritation, or
it  presents itself in the passive form  as the precursor of asthenic inflam-
mation, in  consequence of a paralyzed state of organic innervation; or it 
INTESTINAL CANAL.
59
may be purely mechanical, arising from obstruction to the circulation by
pressure, incarceration of the intestine and its mesentery, contraction of
the large vessels and the heart, impermeability of the  lungs, &c, in which
case it affects the veins chiefly.   In consequence of  the vascular injec-
tion, the mucous membrane of the intestine offers various degrees of red-
ness, or there are slight extravasations or ecchymoses;  or, as is particu-
larly seen in the last two  cases of hyperaemia, the mucous  membrane, or
even the entire membranes of the intestine, may present a uniform red-
dish-black color, the tissue being saturated with  blood, and no injection
of bloodvessels being distinguishable ; the larger vessels, and particularly
the venous trunks are distended even as  far as the mesenteries, and over-
charged with blood (apoplexia intestini).   In either  case hemorrhage
may take place into the cavity of the intestine.
   b. Anaemia of the intestinal mucous membrane occurs  in  connection
with an atrophic state  of the intestinal coats, and accompanying tabes
universalis and general anaemia.   It is often seen as  a  sequel of a rapid
consumption of  the vital  fluids from  excessive diarrhoea and  exhausting
discharges,  and it appears in a very marked form in  the gelatinous soft-
ening  of the stomach and of the intestine in children.   The intestine
presents the color of tissue that has been rendered pale by maceration;
or it may have' the peculiar yellowish pallor of wax.
   2. Inflammations of  the  intestinal mucous  membrane.—We  are
acquainted with a catarrhal (erythematous) and a croupy form of inflam-
mation, and, on account of the prevalence of a dyscrasic  type, we may
consider the typhous and the dysenteric  processes occurring in the  intes-
tinal mucous membrane as allied to the latter.
   a.  Catarrhal inflammation—or  in a lower degree mere  catarrhal
irritation, catarrh—presents itself as genuine entero-catarrhus, with  a
discharge of a thin muco-serous secretion in catarrhal diarrhoeas, namely,
as a consequence  of suppressed  cutaneous  exhalation.  It may result
from mechanical or chemical irritation of the intestinal mucous membrane
by foreign bodies or stagnating fecal matter;  it may also be developed
in consequence of congestive or  venous stasis  in the portal system;  or,
lastly, it frequently shows a specific, contagious property (exanthematic,
typhoid catarrhs), and  appears as a precursor of these  processes or asso-
ciated with them, and in the vicinity of morbid growths.
   Catarrh is either acute  or  chronic, and it either attacks  the mucous
membrane uniformly, or is developed mainly in the villi and follicles.
   The anatomical signs of the acute form are, more  or less intense red-
ness and injection of the mucous membrane, affecting  its entire surface,
or appearing as punctiform reddening from affection  of the villi, or as  a
vascular halo surrounding the follicles;  relaxation of the  tissue, and in-
tumescence of the mucous membrane, equally affecting the entire substance,
or only the villi and the  follicles, opacity of the mucous  membrane  and
its epithelium from infiltration of the former, and softening of the latter)
friability and softening of the mucous membrane.   The submucous  cel-
lular tissue is injected, relaxed, and infiltrated with a watery, opaque
fluid; the secretion is at first copious and serous ; as the  affection increases
in intensity, the former diminishes in amount, becomes  opaque, viscid,
and puriform. 
60
ABNORMITIES  OF THE
   Chronic inflammation is characterized, in addition to the above signs,
by a dark, rusty, livid discoloration, which in severe cases appears to
pervade the entire mucous membrane; by a tumid state of the mucous
membrane and its  follicles,  accompanied by  increased  density of the
tissue,  copious secretion of an opaque, grayish-white, or yellow puriform
mucus.
   Acute  inflammation frequently passes into resolution, but it often
recurs, and may, if the predisposing cause  is not got  rid  of, become
habitual or chronic.   Chronic inflammation rarely admits of a complete
cure.   It  is generally followed by a blennorrhoic condition ; and we thus
find, in well-marked  cases, a  permanent  dilatation of the vessels  esta-
blished, with the following alteration in the tissues:
   A brown,  slate-colored,  or bluish-black discoloration of the mucous
membrane (deposit of pigment,) involving its entire thickness, or the villi
or the follicles only;
   Increase of substance, or permanent tumefaction of  the mucous mem-
brane, its follicles, or villi, with increased density and consistence (hyper-
trophy), giving rise in higher degrees to elongation of  the  membrane,
and formation of folds and polypi;
   Hypertrophy of the submucous cellular tissue and the muscular coat;
   Profuse secretion of a grayish-white and  milky, or  of a transparent
gelatinous and viscid mucus (pituita  vitrea).
   Catarrhal  inflammation occasionally passes into suppuration and ul-
ceration.  This is found to occur in consequence of frequent relapses of
acute inflammation, but more particularly when an acute attack supervenes
upon an existing chronic affection,  or invades a blennorrhoic mucous
membrane.   The mucous membrane is converted into a dark-red, granu-
lated and  friable tissue, on the surface of and within which suppuration
is  established.  This penetrates to the deeper tissues, and thus gives rise
to abscesses, which open  internally; in either case loss of substance is
entailed, which increases with more or less rapidity; ulcers follow, which
are surrounded by tumid, irregular, sinuous, undermined edges, having
a granulating base, and extending into the surrounding cellular tissue or
into the hypertrophied muscular coat.  The suppuration may even pass
through the latter by means of sinuses, in the vicinity of which the mucous
membrane presents the above-described appearances, or is blennorrhoic,
and often  covered with polypous excrescences.   This process is invariably
accompanied by corrugation  and slaty or  bluish-black discoloration of the
intestinal  coats.   Catarrhal phthisis thus occasions a contraction of the
intestinal  canal, which becomes more considerable after  the cure of the
former.   Cicatrization is  effected by a dense,  resisting cellulo-fibrous
tissue, which compresses the mucous membrane in the vicinity of the loss
of substance, or the solitary insular remnants of the mucous membrane
into plicated polypous tumours.
   The seat and extent of the catarrhal inflammation and of the blennor-
rhoea, differ  according to the cause.   They are frequently spread more
or less uniformly over the entire intestinal tract; they are often limited
to a certain portion of the colon or the small intestine, where they occupy
large spaces ; or they may occur in one  or several small circumscribed
spots, in consequence of local irritation.   These affections are peculiarly 
INTESTINAL CANAL.
61
liable to recur as long as the predisposing cause continues; they exacer-
bate from time to time if chronic, and lead to suppuration.   They are
not common in the small intestine, their usual seat being certain portions
of the large intestine, viz. the caecum and rectum.
   A peculiar disease that we must here advert to is ulcerative inflammation
of the follicles of the colon, such as we find in lientery, brought on by
tedious diarrhoeas.   An ulcer  results, which is  distinguished from the
catarrhal ulcer just described, by the shape which it  derives from the
follicle, and still more by the total absence of reaction, which is brought
on by the excessive destruction of tissue, and which produces an atonic
and relaxed state of the tissues at the base.
   In this disease, which in the dead  subject is commonly not observed
until it has committed extensive ravages, the follicles are at first tumefied
in various degrees, and consequently project  as smaller or larger round,
conical nodules on the internal surface of the intestine, being surrounded
by a dark-red vascular halo.   Ulceration now ensues in the  interior  of
the follicle, the small abscess  penetrates the  mucous membrane within
the vascular halo, and a fringed ulcerated opening, of the size of a millet
seed appears, which leads  to  a small  follicular abscess with red spongy
walls.  The ulceration  continues, and the follicle  is eaten away.   The
mucous membrane that loosely surrounds  the enlarged  orifice of the
abscess, overlays the exposed submucous tissue.   In most cases the
hyperaemia of this edge diminishes in  consequence of  the  exhaustion
brought on by the discharges; it becomes pale, or is discolored by a de-
position of black pigment in its tissue, which gives rise to a slaty appear-
ance.  The ulcer is of the size of a pea or a lentil, round or oval, the
mucous membrane at the circumference is pale, slate-colored, livid, and
much relaxed, the cellular tissue at the base is dull white, anaemic, san-
guineous or dark blue.  A flabby typhous ulcer of  the colon is the only
thing that might render the diagnosis uncertain.
   At this period a secondary destruction of the intestinal mucous mem-
brane commences, which  proceeds  with  great rapidity.   The original
follicular ulcer enlarges in every direction, forming sinuses and exposing
the pale, lax, muscular coat at its base.   Several  ulcers coalesce, and Ave
thus frequently find the mucous  membrane  and  its cellular  substratum
destroyed  to  a considerable  extent and  the remaining portion of the
mucous membrane pale  or  slate-colored;  there is general anaemia and
tabes ;  and the contents of the intestinal canal consist of the half-digested
food mixed up with reddish, semifluid, grumous matters.
   We may state it as a rule, that the  lower down the original, as well as
the  secondary process takes  place, the  more fully they are developed.
Hence the most  extensive destruction is found to  occur in the  sigmoid
flexure and the rectum.  It is always confined to the colon.   Occasionally
the  disease runs a still more rapid course, as in infants at the  breast;
and it is then accompanied by  catarrhal irritation of the small intestine.
   On account of the alvine discharges, which are invariably associated
with this ulcer, the  affection may not inappropriately be termed ulcera-
tive diarrhoea.
   b. Exudative processes of the intestinal mucous membrane.—Under
this  head Ave include all  those  products of serous, albuminous, pasty, 
62
ABNORMITIES  OF  THE
fibrinous,  puriform, and  purulent  exudation occurring on the  mucous
membrane, Avhich are more or less  profuse, and  are  preceded by slight
redness and congestion.  Maceration and solution of the epithelium, re-
laxation, and infiltration of the mucous  and submucous tissues, fusion
(as it  were self-secretion) and gradual  disappearance of the  mucous
membrane and its follicles, take place at  the same  time.   The  mucous
membrane is softened and tumid, it is infiltrated Avith the exuded matter,
variously reddened and injected, or pale, or of a  dirty gray or tawny
color.   In proportion to the degree  of vascularity and the quality of the
exudation,  it is more or less pultaceous, and attenuated or entirely de-
stroyed.
  We here also adduce the process  that  takes  place  on the intestinal
mucous membrane in cholera, the acute pituitous condition of the mucous
membrane  (Eisenmann's pyrotic process), genuine croup, puriform and
purulent diarrhoeas, &c.
  These processes probably always  involve a large tract of intestine, and
are the expression of a constitutional affection, which itself may either
be primary or secondary; in the latter case it represents a degeneration
or an anomalous form of the  original disease.   The not unfrequent  de-
generations of specific  cachexia, such  as  typhus, the exanthemata (par-
ticularly variola and scarlatina), acute tubercle  and cancer, which were
originally acute,  or have become so  under certain  conditions, may thus
present the type of the process just described.

  c. The Typhous Process.—The first duty of the pathological anatomist
in this case, is to institute a comprehensive investigation of the local
typhous processes, and  we offer the results derived from the observation of
normal ileo-typhus as it is presented in  the indigenous  form, which is
commonly  very defined in its localization.   On account of the impor-
tance of the subject, we shall  add a summary of the changes  that occur
in other systems and organs in typhus, as well as a synopsis of the more
important anomalies of the typhous process, that we are at present  ac-
quainted with.

     The  Typhous Process in the Mucous Membrane of the Small
                              Intestine.

  The typhous process of the small intestine presents four stages:
  The congestive stage.
  The stage of deposition of the typhous  product,—of  typhous  infiltra-
tion ; the crude stage of the deposit.
  The stage of softening and  rejection of the typhous deposit.
  The stage of the genuine typhous ulcer.
  In the first stage, which corresponds to the period of irritation with a
predominance of catarrhal and gastric symptoms, we observe  on  the mu-
cous membrane of the small intestine, dilatation and stasis in  the venous
system, with swelling, and a  peculiar succulence of the mucous mem-
brane, accompanied by opacity and slaty discoloration.  The  swelling
of the  villous layer is particularly distinct.   This condition affects, more
or less, the entire mucous membrane of the  small intestine, but it deve- 
INTESTINAL CANAL.
63
lopes itself more strongly at some parts than at others, and there generally
appears to be a gradual increase from above  downwards, as far as the
caecal valve.  The inner surface of the intestine is  invested by a thick
layer of dirty, yellow, gelatinous mucus.
   The mesenteric glands are slightly swollen, their  bloodvessels are in-
jected, the tissue itself is elastic, soft and dark-colored.
   In the second stage the  congestion is diminished; the  injection  and
reddening, and even the SAvelling of the mucous membrane, retract within
circumscribed spaces which correspond with Peyer's agminated glands,
or  occasionally Avith  solitary  follicles.   Bounded  or  more commonly
elliptical tumefactions (plaques), varying in thickness from half a line to
three lines, are formed, which result from  the deposition  of a peculiar
substance in the tissue of the Peyerian plexus and of the submucous cel-
lular tissue.  They are surrounded  by a vascular wreath which stops
short at their circumference, and by a marginal plane which rises abruptly,
or is contracted, so as to appear pediculated.  In  the  latter case they
the more resemble flat sessile fungi, as they often  present  an umbilical
indentation at their centre.  According to the amount of matter accu-
mulated, the mucous membrane is more or less  tense, being intimately
blended with the deposit, as this again is firmly and immovably attached
to the muscular coat of the intestines.
   The typhous patches offer a  gray or tawny  discoloration, which is per-
ceptible through the mucous membrane as Avell as through the two exter-
nal coats of the intestine, and they are hard and resilient: Avhen the dis-
coloration is darker, and more of  a bluish-red tint, they are softer  and
more compressible.  They appear, when seen through the  peritoneum,
as insulated spots;  they may  be generally recognized by the varicose
condition of the peritoneal vessels, and they are  perceptible  to the touch
through the tumefaction on the external surface  of the intestine.
   The loAver third of the small  intestine is the common  seat of typhous
infiltration, and the typhous spots are placed  at the side opposite  to the
insertion of the mesentery; they increase in number towards  the caecal
valve.  They vary  in size from  that of a  sixpence  to  half-a-croAvn;
towards the terminal  portion of the small intestine, in correspondence
with the extensive glandular apparatus that exists  here, they occupy a
space of several inches, and end upon the ileal surface of the valve.  Near
and between the patches we find single, round, nodulated  tumors of  the
size of  a hempseed or pea, surrounded by a similar vascular wreath;
these represent the typhous infiltration of a solitary follicle.
   On minute examination  of the morbid product, it proves to be deposited
under the mucous membrane and in the submucous tissue, without involv-
ing the muscular coat.  It presents a substance of more or less density,
of a pale-red color and fibro-lardaceous texture; it is  occasionally tra-
versed by streaks of blood.  The deposit very rarely extends beyond the
follicular apparatus.
   The swelling of the mesenteric glands also  increases; they are of the
size of a bean or hazelnut, blue or  bluish-red, tolerably firm, and appa-
rently infiltrated with a lardaceous mass.
   The commencement of the third stage is marked by a return of A'iolent
congestion to the  small intestine.  The vessels, and especially the veins 
64                   ABNORMITIES OF THE

of the mesentery and their ramifications between the intestinal coats, are
filled with dark-purple and viscid blood.   The mucous membrane again
swells, the villi in particular tumefy, and  on pressure, exude  a grayish-
white opaque serum.
  The most remarkable change is  now effected in  the typhous patches
and in the mesenteric glands; they soften.   The patches become more
tumefied, and if the softening process does not  affect them uniformly,
they acquire an uneven tuberculated surface.  The deposit is converted
into  a grayish-red medullary mass; this may, from the imbibition of bile,
be at once metamorphosed into a dirty-yelloAv or brown slough, involving
the investing mucous membrane.   The slough shrivels up in a vertical
and lateral direction, becoming loose at the edges and pultaceous, split-
ting  in various directions, and detaching  itself from the  lowest stratum
of submucous cellular tissue, by which means it is Avholly or in part dis-
charged ; or the morbid product degenerates, when the epidemy is of very
intense character, into a loose, vascular, fungous growth, which is  tra-
versed by streaks of extravasated blood, or is entirely saturated with blood;
it is  the chief source of profuse intestinal hemorrhages, and is generally
discharged piecemeal without antecedent sloughing.
  This metamorphosis sometimes attacks the entire patch, sometimes it
only affects  single portions or separate folliculi; in the  latter case the
remainder  of the patch  passes  through a retrograde  metamorphosis;
absorption causes it to collapse, and a lax, succulent, plicated tumefac-
tion  of the glandular plexus remains.   Accordingly, the above-mentioned
slough is in the  former instance  embraced by the mucous membrane,
which invests the marginal surface of the typhous patch ; in the latter,
by the retrograde1 portion (retrograder antheil)  of  the glandular plexus.
  A similar metamorphosis takes place in the tumefaction of the solitary
glands, though it appears to commence later, and to advance less rapidly ;
the sloughs  are small and rounded, and seem  generally  to undergo the
retrograde process.
  This metamorphosis commences in the neighborhood of the caecal valve,
and is commonly in advance of that which takes place at the upper part
of the ileum.
  The intestine is more or less distended with gas (meteorismus); it also
contains yellow or brownish muco-gelatinous  or biliary  matters, mixed
up with grumous, furred  particles; it ahvays occupies a Ioav position  in
the hypogastrium, and even sinks into the pelvic  cavity.  The caecum
is very often found to  contain the  trichocephalus dispar in larger  or
smaller numbers.
  The mesenteric  glands,  which almost  invariably  pass through  the
stages of the metamorphosis with less rapidity than the typhous pro-
ducts in the intestine, now attain their largest bulk; they reach  the size
of pigeons'  eggs', and, in the vicinity of  the  caecal valve, even of hens'
eggs, and form a tuberculated  chain  which extends in a slanting direc-
tion  from the terminal portion of the ileum to the lumbar plexus.  Their

  1 [The terms " retrograde" and " retrogression" are intended to designate the return of a
diseased part to its normal condition by absorption  of the deposit, or otherwise. They have
been  adopted from the absence of any terms which exactly convey the author's  meaning
—Ed.] 
INTESTINAL CANAL.
65
color is blue  or bluish-red;  they are much congested, and  the vessels,
spread out in the cellular capsule of the gland, present a vascular net-
work which is  perceptible through the mesenteric laminae.   Their sub-
stance  is firm,  but  they are soon  converted into a grayish-red,  lax,
medullary  matter, in which we frequently discover extensive extravasa-
tions of blood;  they then  become  soft  and elastic,  or even  present
distinct fluctuation.
  Fourth stage.  After the morbid product has been detached, a cavity
remains  on the internal surface  of the intestine,  which represents the
true typhous ulcer.
  If the entire morbid  growth is removed at once, that portion of the
intestinal mucous membrane Avhich invested the marginal surface of the
heterologous product  sinks  doAvn  upon  the  ulcer,  and thus  forms a
mucous fringe, which varies in width and extent according  to the pre-
vious elevation (thickness) of the morbid growth ; and from being at first
dark-red, subsequently assumes  a blackish-blue or slate-gray color.  If
the morbid growth has only been partially detached, the remaining por-
tion of the patch becoming  retrograde, Ave  find the smaller ulcerated
surface equally surrounded by a margin of glandular tissue.
  In the former case the base of the ulcer corresponds in form and size
to the  previous infiltration (plaque); varying in size, it is either round
or,  more frequently, elliptic ; the latter shape prevails at the terminal
portion of the  ileum, and  the long diameter  of the ulcer  corresponds
with the longitudinal axis of the  intestine.  In the second case the ulcer
is,  at  all  events, smaller  than the  entire  Peyerian  gland, its shape
irregular,  the  margin  sinuous  or round.   Several ulcers are  often
grouped together.   For the  typhous  infiltration of a  solitary follicle a
circular or slightly oval ulcer is substituted.
  The deep submucous cellular layer, which  invests the  muscular coat,
forms the base of the ulcer.
  The mesenteric glands decrease  in size, as  soon as the detachment of
thcintestinal morbid growth has commenced, in proportion as the gray-
ish-red medullary substance, with which they  are infiltrated,  is removed,
though they  still  continue larger than  they are in the healthy condition:
in  consequence of  the enduring  congestion and  enlargement  of the
vessels they present a reddish-blue tinge.
  The typhous ulcer consequently  presents the following characters :
  Firstly.  Its  form is elliptical  Avhen  it corresponds to the infiltration
and detachment of a larger patch of Peyer's glands; it is round when it
corresponds to  a  solitary follicle  or a  rounded patch, or to  the partial
detachment of  a glandular plexus ; and, lastly, it may also be irregular
or sinuous  when corresponding to a partial detachment.
  Secondly.  The size or circumference of the ulcer varies, from that  of
a hemp-seed  or a pea to that of half-a-crown.
  Thirdly. The position is peculiar in reference to those of an elliptical
shape ; they are  placed opposite to the insertion of the mesentery, and
their long  diameter  is always parallel  to the longitudinal axis of the in-
testine ;  the  typhous ulcer  never forms a zone; at least, we have only
once seen this occur in many hundred  cases.
    VOL. II.                         5 
66
ABNORMITIES  OF  THE
   Fourthly.  The margin of the ulcer is invariably formed by a Avell-de-
 fined fringe of mucous membrane, which is a line or more Avidc, detached,
 freely movable, of a  bluish-red, and subsequently of a slaty or blackish-
 blue color.
   Fifthly. The base of the ulcer is formed by a delicate layer of submu-
 cous tissue which covers the muscular coat; like the marginal substance,
 it is quite void of morbid growth.
   Sixthly. The small intestine is the seat of the  ulcerative process, and
 the lower third is most liable to be involved—the  number and size of the
 ulcers increase as they advance towards the caecal ATalve.
   The cure of the typhous  ulcer to be complete, requires several  local
 and  general  conditions, of which the  chief are the termination of the
 local  process, and the  complete extinction  of the  typhous dyscrasia.
 When such favorable circumstances occur, the cure is effected in the fol-
 lowing manner:
   The fringe of mucous membrane Avhich lies upon the base of the ulcer,
 gradually connects itself, from without imvards, with the cellular tissue
 that invests the base,  and uniting with it becomes paler and thinner. At
 the same time the cellular layer  becomes Avhiter and  denser,  and is
 finally converted into  a  serous lamina, the circumference of Avhich is dove-
tailed between the muscular and mucous coats.  The margin of mucous
membrane is bevelled off in such a manner, that the union is  impercepti-
 ble ; the former does  not  advance  uniformly on all  sides towards the
 centre of the ulcer, hence the elliptical is conArerted into a sinuous, the
round into an  elliptical ulcer.   At the same time the margin, as well as
 the neighboring mucous membrane, are thinned down in such a manner,
that at last their villi appear to  have been  transferred to the serous
lamina.  The  edges unite finally at one or  more spots, and  coalesce.
We have sometimes obsenred, that long  before the union of the edges,
 small Adllosities formed independently on the serous lamina, a fact Avhich
 has been also remarked by Sebastian.
   Instead of  the ulcer we  find, in  proportion as the above process is
 effected,  a slight depression  on the  internal  surface of the intestine, de-
 pendent  upon  the thinning of  the mucous membrane and its  connection
 with a thin cellular layer of denser structure,—or  we find a spot at which
 the mucous membrane is more firmly attached and less movable, in the
 middle of Avhich, by oblique light, we  may often  discover  a  smooth re-
 mainder  of the serous lamina of the size of a millet-seed ;  or, if even this
 is not  the case, we discover a spot at which the mucous membrane is
 more tense, void of plicae, smooth, less vascular than the surrounding por-
 tion, and particularly less villous.
   Such cicatrices have occasionally been observed thirty  years after the
 typhus had occurred.
   It is singular, and characteristic of the typhous ulcer and its cicatrix,
 that it never in any way gives rise to a diminution of the calibre of the
 intestine.
   The mesenteric glands in the meantime have returned to their normal
 size;  they not unfrequently  shrivel up, so  as to become considerably
 smaller,  and at the same time  tough and pale. 
INTESTINAL CANAL.
67
        Summary of the Alterations occurring in other Organs.

  a. In the abdominal cavity.—We find that here only the spleen and
the venous system of the fundus ventriculi offer important and constant
changes, although these  do not  belong exclusiArely to  typhus,  and still
less to ileo-typhus.
  The spleen is  enlarged to from tAvice to six times its  natural size, it
swells, and its sheath becomes tense and smooth ; the tissue of the organ
is friable, and contains a dark purple  or  blackish-red, semi-coagulated,
pultaceous, or perfectly fluid mass,  which gives rise to  a tumor of  pecu-
liar appearance,  occasionally communicating the  sense  of fluctuation;
not unfrequently a spontaneous rupture of the organ ensues.
  At the fundus ventriculi we find  venous  congestion, which may be
traced back to the vessels of the spleen, and Avhich is either limited to
the larger trunks or  affects the capillary vessels in the tissue of the
mucous membrane;  in the latter  case, the  mucous  membrane of  the
fundus  is dark red,  lax, and turgid, and, in consequence, similar to the
condition  of the spleen, rather more friable than in  the normal  state.
Allied to this condition is the first stage of softening, which,  however,
does not appear in the ordinary course of typhus.
  b. In the thorax.—The bronchial mucous membrane and the paren-
chyma of the lungs  present certain constant  changes, Avhich,  however,
vary in degree.
  The former is affected by a peculiar catarrh, accompanied by dark-red
discoloration, and the  secretion  of  a  A'iscid gelatinous  mucus, which in-
creases in amount as we descend to the  smaller subdivisions of  the
bronchi;  the pulmonary parenchyma presents  symptoms of hypostatic
congestion, which is  generally limited to  the posterior and lower por-
tions ; the tissue appears dark red, or purple, is filled  with dark-colored
glutinous  blood,  is  denser, and resembles the spleen  in consistency
(splenification);  this is sometimes increased to hepatization (pneumonia),
though it is to be carefully distinguished from secondary, and still  more,
from primary pneumonic typhus.
  The heart is commonly flaccid, its muscular portions are pale, or of a
dirty-red  color,  but  without any further  anomaly, and more especially
without that softening  of its substance described by Stokes as occurring
in the typhus fevers  of Ireland.   The endocardium and the lining mem-
brane, or  all the coats  of the  vascular  trunks,  frequently  present  a
brown or purplish discoloration produced by imbibition.
  c. Alterations in  the nervous system.—The brain and the spinal cord
and their membranes present the most various gradations with reference
to the amount of blood they contain, from hyperaemia to anaemia; they
sometimes are characterized by remarkable density and tenacity,  some-
times by a humid and softened condition.
  The double condition which  is frequently and distinctly seen in the
central ganglia of the vegetative system, is of still greater importance,
and the results obtained at  the Viennese  Hospital, since the year  1824,
with regard to this question, are in the main corroborated by the obser-
vations made at  the  Wurzburg school  of medicine. 
68
ABNORMITIES OF THE
   The  ganglia of the solar and  superior mesenteric plexus are, in the
 first stages of typhus, in a state of turgescence, Avith a blue or greenish-
 red  discoloration;  they are softened in the ulcerative  stages, and sub-
 sequently  we find them  collapsed, pale, flaccid, shrivelled up as it were
 into coriaceous, tough, Avhite or grayish masses.
   We have  never discovered in the nervous system the  characters  of
 genuine inflammation, a fact which is also  established by  the investiga-
 tions of Hey, in opposition to those of Grossheim.


       Summary of the most remarkable Anomalies of the Local
                           Typhous Process.

   An acquaintance with  the  many anomalies of this process is of such
 importance, that we would not trust a person ignorant of them to judge
 of a post-mortem examination in a case of acute fever.   Their diagnosis
 is the result  of researches Avhich we have for many years devoted to the
 subject.   We add a list of  the anomalies, and subjoin the most essential
 explanations at once:

   1.  Anomalies in reference to the amount of  the  process occurring on
the intestinal mucous membrane.
   a.  Arrest  of its development.
   a.  Arrest  in  the congestive stage—diffused typhous process in the
intestinal mucous membrane.
   /?.  Imperfect  development of the patches—Ioav plasticity of the mor-
bid product.   This variety is allied to the diffused form.
   y. Retrogression (retrogradwerden) of the morbid growths by absorp-
tion ;—to this head belong Chomel's plaques a surface reticulee.
   d.  Slow  metamorphosis of the morbid growth, tardy separation of the
slough, and purification of the ulcer.
   e.  Scanty  formation of the morbid growth.
   b.  Excessive development of the local process.
   a.  Tumultuous1 (tumultuarisch) metamorphosis of the morbid growth,
violent  congestion of the intestine, unusual turgescence of the morbid
growths.   The  congestion  not unfrequently gives  rise to peritonitis,
which proceeds  from one of the patches;  or an extravasation of blood
occurs between  the intestinal  coats, and in their tissue; intestinal apo-
plexy, or a fungoid degeneration of the morbid growths  takes  place,
and  death ensues  from  excessive vegetation,  by  paralysis,  or from
exhaustion by hemorrhage (haemorrhagia intestinalis).
   /3.  Numerous  formations of  morbid growths—extension of the same
to the solitary follicles.
   y. Extension of the process beyond the ileum to the jejunum and
stomach, or to the colon.

  1 [The German word " tumultuarisch" implies, violent symptoms taking place with sud-
denness and rapidity; Rokitansky has himself used the term in a new sense ; the translator,
to avoid frequent circumlocution, has therefore ventured to employ the word "tumultuous"
as most adapted to convey  the author's exact meaning.—Ed.] 
INTESTINAL CANAL.
69
   2.  Anomalies in quality.
   a.  Impeded cicatrization of the ulcer—it assumes the torpid form.
   b.  Degeneration into a perforating typhous ulcer.
   These tAvo forms constitute genuine  typhous intestinal phthisis.   We
have  seen that the local condition for the cure of the typhous ulcer con-
sists in a complete termination of  the local  morbid process in the intes-
tinal  mucous membrane, and a perfect purification  of the ulcer  of all
morbid growth, and  that, as  a general condition, an extirpation of the
typhous and  of every secondary  dyscrasia is  required; it is therefore
evident that the degenerations of the  typhous ulcer Avhich we  are now
considering may be  complicated  Avith  a variety of anomalies; of these
some  have already been considered.
   Perforation of the intestine by the  typhous ulcer constitutes a very
remarkable phenomenon.   How is this effected ?   The typhous process
invariably meets with an  isolating tissue in  the loAver stratum of the
submucous  cellular layer and  of the  muscular  coat; the  destructive
process which occurs beyond  the mucous  membrane, is therefore not the
result of a previous typhous affection (infiltration), but of an essentially
distinct  process.   It is  this that  affords a marked distinction between
the perforating typhous  and the perforating tubercular ulcer.   The pro-
cess by which perforation of the intestinal  parietes  at the base of the
ulcer is effected, is softening  or  mortification of the tissue;  the slough
that results only affects the deepest parts of the ulcer to a  small extent,
and we rarely find the orifice  larger than a pin-hole,  or a millet or hemp-
seed.
   The varying  period at Avhich in the  course of typhus the ulcer dege-
nerates  in  this manner, is remarkable, as also the rapidity with which
occasionally the perforation  is effected.  We  have observed it  occur
rapidly in ulcers that had scarcely formed, whilst the remaining morbid
growths were engaged in the metamorphosis, or eAren in the crude stage;
and again we have seen  it occur slowly or  quickly at  every  subsequent
stage;  long after the termination of the  local process, and  even after
the genuine typhous had subsided into  the atonic  ulcer.
   The  consequence of the intestinal  perforation, and of  the resulting
effusion of the intestinal contents into the peritoneal cavity is peritonitis ;
it generally gives rise to tolerably copious, but uncoagulable  and liquid
exudation;  it frequently takes place even before  actual perforation  has
ensued, and is developed as soon as the  process of perforation approaches
the peritoneum.
   The exudation commonly induces an  adhesion between the  perforated
coil and another coil, or between its mesentery and the pelvic parietes;
Avhich may certainly be looked upon as an effort  of  the vis medicatrix
naturae., but which our investigations have proved, never to effect a
radical cure of the typhous perforation of the intestine.
   Our experience with regard  to the perforating process, does not, except
in rare cases, allow us to concur in the  view  adopted  by several  French
observers of distinction, that it is to be considered as a rupture of  the
ulcerated part; nor can we sanction the doctrine of Judas, that the intes-
tine, when on the point of being perforated, moves into the pelvic cavity,
in order to find suitable spots for adhesion, inasmuch as the typhous intes- 
70
ABNORMITIES  OF  THE
tine sinks into the lowest region of the abdominal cavity long before the
ulcerative degeneration takes place.


Appendix.—Anomalies in reference to the Begree and Character of the
             Typhous Process in the Mesenteric Glands.

  1. Tumultuous metamorphosis of the typhous  product  in the mesen-
teric glands.
  This sometimes consists in very violent congestion of the gland, which
not unfrequently gives rise to inflammatory injection of the mesenteric
laminae above the gland; or  great tumefaction takes place, and the gland
is converted into a medullary, ichorous pulp ; or, lastly, a fungous growth
forms, which perforates  one of  the mesenteric laminae,  commonly the
anterior one.  General  peritonitis is  a frequent consequence of  these
occurrences; in  the last instance  we have, as in the case of intestinal
hemorrhages, extravasations  into the peritoneal sac.  This anomaly gene-
rally occurs in a gland that  is seated near the termination of the ileum,
and is accompanied by  a tumultuous  metamorphosis in  the intestinal
mucous membrane.

  2. Atrophy of the mesenteric glands.
  The involution of the mesenteric glands after the termination of the
typhous process is sometimes carried to excess, and an atrophy of these
glands results.   They then  appear shrivelled,  flaccid, coriaceous, per-
fectly bloodless, pale or gray, or even of a dark blue  color.   Occasionally
the atrophy is less perceptible, as the gland appears of  its normal,  or
even beyond its normal size; this, however, is only the consequence of
passive congestion or stasis,  from dilatation of the vessels, Avhich are full
of blood, and give it a bluish-red color, the glandular tissue itself  being
diminished.
  The typhous ulcer of the  intestine at the same time  assumes a torpid
condition, or it may have advanced, in some measure, to cicatrization.
  We shall show at a future period hoAV this condition forms an impor-
tant anatomical basis for the constitutional debility consequent upon
typhus.

  3. Secondary typhous processes.
  An acquaintance with these processes is the more important, as they
throw much light upon the nature of typhus, as they have hitherto been
but little known, and as their connection with  the primary disease is
commonly overlooked.  They almost invariably present anomalies in re-
ference to the seat  of the typhous process; several of them are remarka-
ble for the frequency of their occurrence.   They are to be distinguished
either as genuine or as degenerated typhous processes.
  Genuine secondary typhous processes generally  depend upon marked
anomalies  in the degree of the primary process.  The  most exquisite
form in which they present  themselves is seen in the mucous membranes,
which we must consider as the true nidus of the typhus.
   a.  Secondary processes in mucous membranes. 
INTESTINAL  CANAL.
71
   «. Recurrent eruption of the mucous membrane of the small intestine.
—We  may find typhous patches of recent formation in the crude stage,
intervening among typhous formations which are undergoing the metamor-
phosis  or at the side of the typhous ulcer.  These must be carefully dis-
tinguished from the patches Avhich are less advanced in their development.
This eruption is  occasionally seen in a  very undeveloped state, in the
form of miliary swelling of the solitary follicles.
   /?. Secondary typhous process in  the  mucous membrane of the colon
and stomach;—secondary colo-typhus, secondary gastric  typhus.—The
latter is a rare occurrence ; it stops short at the congestive stage when it
does take place, and very rarely presents the nodulated form of the typhous
deposit.
   y. Secondary laryngeal typhus.—This is a secondary typhous process
of considerable importance, both on  account of its frequency and on  ac-
count of its  unfavorable prognosis.  Its seat is the posterior surface of
the larynx and the edges of the  epiglottis;  it not unfrequently gives rise
to typhous laryngeal phthisis, accompanied by necrosis of  the cartilages.
   d. Secondary pharyngeal typhus  occurs much more rarely than the
former, and never except in company with it.
   e. Secondary bronchial and pneumonic typhus.
   This must be carefully distinguished from the hypostatic  pneumonia
frequently developed in the course of typhus, as well  as  from capillary
phlebitis of the lungs.
   Z. Secondary typhous process in the vesical mucous membrane.
   rj. Secondary typhous process in the mucous membrane of the female
sexual organs.
   b. Secondary typhous processes in serous membranes.—Among these
Ave reckon  the typhous inflammations of  the pleura, of the meninges, of
the capsule of the aqueous humor, and of the internal coat of the vessels
(Phlebitis typhosa).
   c. Secondary typhous processes in  parenchymatous organs.—These
are the typhous inflammations of  the liver, the  spleen, the parotid, and
the ganglionic substance of the brain and spinal cord.
   The degenerated secondary typhous process occurs  in various forms ;
in almost all of them  a suspicion arises of the existence of a disease
analogous to  typhus, and this fact offers the  more interest, as we have
arrived at similar results  in our special investigations of  the morbid
anatomy of ileo-typhus.  Autenrieth describes them as neuroparalytic
inflammations, Schonlein as neurophlogoses, Eisenmann as pyra, Buzorini
under  the  head of typhus.   They are based upon  a corresponding de-
generation of the  typhous  process in the blood, and may be  classed  as
folloAvs :
   a. Degeneration into croupy  inflammation.—This includes the  entire
exudative processes of  the mucous membrane, of the respiratory organs,
the oesophagus, the stomach, the  intestinal  canal, the  female sexual
organs; as well as all the secondary exudative  processes occurring  on
serous  membranes; and the exudations  that ensue on the cellular and
muscular base of the typhous ulcer, as a  degeneration of the local affec-
tion of the intestinal mucous membrane.
   ft. Degeneration into acute softening.—To this class  belong first of all 
72
ABNORMITIES  OF  THE
 the remarkable and frequent cases of black ramollissement of the fundus
 ventriculi and the oesophagus in Avhich the spleen sometimes participates,
 and which originates in the vascular system ; and in a second degree the
 softening of the pulmonary parenchyma, and  of the mucous membrane of
 the bladder.   When occurring as a degeneration of the local process, it
 is found at the base of the typhous ulcer, and may superinduce perfora-
 tion of the intestine. (Vid. p. 69.)
   y.  Degeneration into gangrenous inflammation and primary gangrene.
 —This includes the well-known  phenomena  occurring in the course of
 typhus in the shape of noma, gangraena pulmonum, sloughing of the nates
 (decubitus), of parts  to which vesicants  have been applied, and of the
 female sexual organs.   It may occur as a degeneration of the local pro-
 cess, and by sloughing  at the base of the typhous ulcer induce perforation
 of the intestine.
   d.  Degeneration into a  process in Avhich pus, or rather a fluid analo-
 gous to pus is formed.—This involves suppuration  of the patches and of
 the typhous ulcer, in the mesenteric glands; asAvell as suppuration in the
 lungs, the spleen, the liver, the parotid, in the subcutaneous cellular tissue,
 betAveen the muscles,  &c.
   Besides these anomalies, there are other sequelae of  typhus, which are
 based upon a permanent depression of the entire vegetative system,  such
 as tabes universalis; or upon a diminution of nervous power, as  obtuse-
 ness of the senses or paralysis; or again upon continued irritation, as
 hydrocephalus; or lastly,  upon  a secondary constitutional disease, as
 presented in oedema, anasarca, permanent suppurative  processes, and
 Bright's renal disease.
   The depression of the vegetative system remaining  after typhus de-
 mands special investigation.   It  is presented either as a very slow pro-
 gress of convalescence, or in the advanced degree as genuine tabes ; both
 forms are distinguished by their  peculiar type.   The following are the
 anatomical points which characterize them :
   a. Genuine intestinal phthisis, or where a cure of the intestinal ulcers
 has begun, or is almost  terminated, a loss of villi and follicles ;
   /?. A shrivelled condition  or  marasmus of  a  considerable number of
 mesenteric glands; and
   y. The  flaccid atrophic condition of the abdominal ganglia, and more
 especially of the solar and superior mesenteric plexus, Avhich, as well as
 the former,  we  have already adverted to.

                             EPICRISIS.

   Firstly.   Typhus is characterized anatomically and in reference to the
alterations in the solids, by the deposition of a peculiar product which
undergoes a peculiar metamorphosis.
   Secondly. Its habitat varies  and depends upon the specific relation
existing between the general disease  and certain organs.   Indigenous as
well as exotic typhus show the mucous membranes and the lymphatic
glands to be the chief seat; in Austria it is chiefly the mucous membrane
of the small intestine,  yet even  here bronchial and pneumonic typhus
occur as a primary affection, and ought probably to  be considered as the 
INTESTINAL CANAL.
73
  basis of the exanthematic form ;  we also, though  very rarely  meet with
  colo-typhus.                                              J'
    Thirdly. The product of  typhus presents in its first, but still more, in
  its later  stages  of metamorphosis, the greatest  analogy Avith cancerous
  groAvths,  and more particularly Avith medullary cancer.1
    Fourthly. The local typhous process is a species of inflammation;  but
  not one of  those to which we attribute a phlogistic crasis of  the blood
  but one which, on account of the  peculiar diseased condition of the blood'
  we term typhous.
    Fifthly.  The local affection of  the mucous membrane of the small in-
  testine, is  a  constant  accompaniment  of the  typhus seen  among  our-
  selves ; but as, according to our  previous observations, it may occasion-
  ally be subject to> an arrest of development, we find solitary exceptions
  in which there is no intestinal affection;  in that  case it is necessary to
  watch the other mucous membranes closely, or, indeed, the process, with-
  out being localized, may run its entire  course in the blood.
    It is well knoAvn that typhus occurs chiefly during the period of puberty
  and during  the prime of life;  before and after this  epoch, it is very un-
  frequent; Ave must however  guard against considering every typhoid ap-
  pearance in Peyer's patches, during the  early years of life, as genuine
  typhus.  The predisposition seems to disappear with the involution of the
  sexual^ powers; still it does /)ccur now  and then, after the sixtieth and
  seventieth years of life.
    Typhus presents a peculiarly interesting negative relation in reference
 to its capability of  forming  combinations.   Pregnancy offers an almost
 entire  immunity from typhus, lactation less so, and cases in which it is
 complicated with  tubercular  affections,  with  cyanosis, cancer and  the
 cancerous cachexies are  exceptional, Avhereas it is frequently complicated
 Avith syphilis and gonorrhoea.
   d. The Bysenteric Process.2—We are acquainted Avith the dysenteric
 process  as a substantive disease of the  mucous membrane  of the colon,
 and inasmuch as it is here presented in its most exquisite form, its habitat
 has been correctly fixed  ever since the days of Hippocrates.
   The dysenteric process is divisible into four natural  degrees or forms.
   In the lowest degree, the mucous membrane commonly presents a layer
 of a thin secretion, of a  dirty gray and  reddish color, underneath Avhich,
 certain parts, commonly  the projecting  folds of the  mucous  membrane,
 are reddened and swollen.  In this manner striae  are produced, which
 more or less encircle the intestine.  The epithelium  is either raised  in
 the. shape of small vesicles which contain clear serum, or it forms a gray-
 ish-white layer, resembling the mealy scurf of the epidermis,  an appear-
 ance which probably induced  Linnaeus to term dysentery Scabies intesti-
 norum  interna.   The subjacent  mucous  membrane seems excoriated,
 slight pressure induces hemorrhage, and it may be easily detached in the
 shape of a light red sanguineous  pulp;  its submucous  cellular tissue
 appears infiltrated.

  1 We must leave a further development of this doctrine to oral instruction.  Dr. Mohr, in
his Contributions to Pathological Anatomy (Stuttgart, 1838, p. 131), quotes, in connection
with this subject, an authority which is quite foreign to the matter.         ^
  2 Vide Oestr. Jahrb. xx. I. 
74
ABNORMITIES  OF  THE
   The anatomical characters may be summed up as—swelling, injection
and  reddening, softening (red and bleeding), serous  exudation in the
shape  of  a  delicate vesicular eruption and consequent  branny desqua-
mation of the epidermis.
   In the second degree, the  textural alterations are not limited in the
manner described, but  extend OArer a larger surface, still, hoAvever, pre-
senting a greater development at one part than at another.  The mucous
membrane is invested to the  same extent, by a dirty-gray layer, consist-
ing of  desquamated epithelium and  a thick glutinous exudation ;  or this
may already have been remoATed, and  the subjacent mucous membrane,
in either case, appears converted into  a soft, sanguineous, pale-red and
yelloAvish gelatinous substance, Avhich may be easily detached.  The  in-
ternal  surface of the intestine commonly presents more or less numerous
protuberances, which closer examination proves to  consist  of  a  very
copious infiltration of the submucous cellular tissue  : these projections or
tumors Avere first observed by HeAvson  and Pringle ; other authors speak
of them as warty tubercular SAvellings, or fungoid excrescences, and  M.
GeTy has lately termed  them Hypertrophic  mamelonnee du tissue  sous-
muqueux.
   They correspond to those  points of the mucous  membrane at Avhich
the morbid affection is most developed; with the exception of  slight red-
ness and intumescence, especially in the circumference  of the follicles, an
increase in the mucous secretion, and a slight desquamation of epithelium,
the intervening parts  of the mucous membrane do not generally offer any
marked textural changes.  The entire portion of intestine is generally in
a state of passive dilatation ;  it is distended with  gas and  Avith a  dirty
broAvn  fluid, Avhich consists of the most different materials, such as intes-
tinal secretions, epithelium, lymph,  blood, and faeces ; its coats are thick-
ened, and the submucous tissue particularly is in a  state  of tumefaction.
   At this stage we meet with the laminated and  tubular coagula in the
evacuations, described by ancient and  modern  authors, especially if the
exudation be of a more  plastic character.
   Occasionally the affection  of the follicles predominates and is accom-
panied by irritation, exhausting secretions, and softening : these probably
constitute the  characteristic  signs  of  the  so-called catarrhal or Avhite
dysentery, but which, in an anatomical point of view, is the  same  folli-
cular affection of the colon as that  Avhich we have  already described as
accompanying chronic diarrhoea.
   In the third stage, we find the protuberances more closely set,  so as
to produce an uneven,  lobulated  appearance.  The mucous  membrane
that inATests these protuberances partly retains the  above-described con-
formation ; in part it is  converted into a slough, which is here and  there
blended Avith the desquamated epithelium and the exudation, and is firmly
attached to them ; it  is  of a dark-red or blackish-broAvn, sugillated  or
grayish-green color ; or the  mucous membrane may have disappeared,
so as to  expose the infiltrated submucous cellular tissue to  which the
remnants  of the mucous membrane remain attached in the shape of
solitary,  dark-red, flaccid, and bleeding vascular  tufts, or  as  dilated
follicles,  Avhich are  easily removed.    The  interstices  of  the mucous
membrane are the seat of the affection in a loAver degree.
   The protuberances  occasionally are found  to have coalesced, and the 
INTESTINAL CANAL.
75
intestine then presents  an uneven plicated surface, accompanied by an
equable degree of infiltration and thickening of its parietes; the  mucous
membrane is  uniformly affected  over a large extent, and  there are no
free interstices.
  The contents of the intestine are of a dirty-brown or reddish, ichorous,
fetid, flocculent  and grumous character.
  In the fourth and highest degree, the mucous membrane degenerates into
a black, friable, carbonified mass, which may often be subsequently voided
in the shape of tubular laminae (so-called mortification of the mucous mem-
brane).  The submucous cellular tissue appears to be previously infiltrated
with carbonified  blood, or a sero-sanguinolent fluid; or it is pallid,  and the
blood contained  in its vessels is converted  into a black, solid or pulveru-
lent mass: subsequently it shows purulent infiltration, in consequence  of
the reactive inflammation which is induced in the lower  healthy strata,
for  the purpose of  eliminating  the gangrenous portions.
  The affected portion of intestine,  which contains a putrid, broAvnish-
black fluid, resembling  coffee-grounds,  may appear in a state of  passive
dilatation, as  above described,  but it is much more frequently collapsed ;
and if the two highest degrees  continue for any length  of time, the mus-
cular coat will be reduced.  The tissue of the latter is condensed, pale,
ashy, peculiarly elastic and friable,  and analogous to the yellow fibrous
tissue.
  The peritoneal coat presents, in  the higher, and particularly in the
highest degree of  the  affection,  a  dirty-gray discoloration, and  a total
absence  of lustre; at intervals it presents a dilatation and injection of its
capillary vessels, and is invested with a  brownish, ichorous exudation;
occasionally the meso-colon, and  even the mesenteric laminae, that have
been in  contact with them, participate in the affection.  This affords a
means of distinguishing dysenteric  disease of the intestine on its outer
surface.
  The glands of the meso-colon present  a  corresponding  tumefaction;
they are of a dark-blue color, congested and tumefied; but we have not
succeeded in detecting in  them a  peculiar (specific) solid morbid product,
as we have in typhus.
  The mucous membrane of the colon is,  as aat6 have already observed,
the seat  of the dysenteric process;  and we  may state it as a rule, that
its  intensity increases from the  caecal valve downwards,  and  consequently
is met with, in the  most fully-developed state, in the sigmoid flexure and
in  the rectum.   It not unfrequently  passes  beyond  the  caecal valve,
tOAvards  the ileum,  but  is  here only seen in its mildest form.
   It commonly runs an acute  course, though it is frequently chronic in
the milder degrees  ; this, however, does not materially alter its character.
   The manner in which it terminates varies.
   1.  The disease is fatal, in consequence  of the  more or less rapid,  or
more or  less penetrating destruction of tissue, and the coincident exhaus-
tion.
   2.  The disease  may terminate in cure, if the mucous membrane has
not become disorganized in the manner above-described, the normal cohe-
sion returning, and a new layer being generated under the desquamated
epithelium. 
76
ABNORMITIES  OF THE
   3. In the higher degrees of the disease, when disorganization has oc-
curred in one of the above-described  processes, and the mucous mem-
brane has suffered more or less extensive destruction, one of two results
ensues:
   a. A real cure of the loss  of substance, Avith consolidation of the
abraded portions of the intestine follows ; or,
   b. The entire process assumes a Ioav chronic form, the specific nature
of the disease is lost, and we have atonic inflammation and suppuration
of the intestinal coats.
   If a cure ensues, the portions of mucous membrane Avhich were affected
in a loAver degree are first restored to their normal condition ; between
them are small patches, or more extensive spaces, with a sinuous circum-
ference, at which the mucous*membrane is deficient, and the submucous,
pale, infiltrated cellular tissue is exposed.  Not unfrequently Ave perceive
detached remnants of mucous membrane adhering to these parts.  The
exposed submucous cellular  tissue is gradually converted, as-proved by
cadaveric examinations at the most various periods after the cessation of
dysentery, into serous tissue ; this is further condensed  into sero-fibrous
tissue,  and by it the sinuous portions of mucous membrane, at the edge of
the impaired surface, are, like the isolated remnants of mucous membrane,
compressed  into Avarty, pediculated  (polypous) prolongations, and thus
the originally sinuous circumference  obtains a fringed, dentated appear-
ance.  In cases in which the loss of substance is inconsiderable,  the new
tissue may contract  so as to bring the  edges of  the mucous  membrane
into apposition with one another and Avith the polypous remnants of mu-
cous membrane, and the cicatrix is then represented by a large number
of agminated  warty excrescences of the mucous  membrane, between
Avhich the sero-fibrous basis from Avhich they proceed, may be detected.
   In cases of extensive destruction of substance, the approach of the edges
is rendered impossible;  the deeper layers of the tissue,  which  takes the
place of the mucous membrane,  is  frequently condensed into  fibrous
bands, which form corded projections into the intestinal  cavity, interlace
with one another, and not unfrequently encroach upon the calibre of the
intestine in the shape of valvular or  annular folds, thus giving rise to a
stricture in the colon of a very peculiar form.  This mode of  regenera-
tion is the more remarkable, as it closely resembles that following the
destruction of the oesophageal mucous membrane by mineral acids.
   In the second case the specific affection terminates after having pre-
viously given rise to moreor less extensive disorganization, but without
being followed by the healing process just described.   The entire disease
now assumes a chronic character, and appears on the residual portion of
mucous membrane as chronic catarrhal inflammation, the follicles being
more or less prominently affected, and suppuration occurring in the shape
of sinuses and abscesses under the mucous membrane, and between the
external coats of the intestine ;  at the same time the intestinal canal con-
tracts, its coats assume a rusty, dark-blue  color; there is  occasional
exacerbation of the peritoneal irritation, and the intestine becomes fixed
in consequence of exudation and infiltration in its cellular sheath and its
mesentery.  In this case the mucous membrane is found of a dull  red
color, tumefied, and invested by a copious secretion of a glairy or purulent 
INTESTINAL CANAL.
77
character; the follicles, particularly those at the end of the colon, are
dilated, distended by a glassy pituita, or in a state of suppuration; there
are small abscesses, of the size of a hemp-seed or pea, under the mucous
membrane, and in the cellular  tissue lying  betAveen the muscular fibres.
These abscesses  open upon  the  mucous  membrane by the suppurating
follicles or by other minute orifices, forming fistulous passages in various
directions, and penetrating  into deeper parts, so as to reach the peri-
toneum, and  there induce inflammation; or they give rise, in the Adcinity
of the rectum, to the formation of large abscesses, as described by  Mor-
gagni.
   The concurrent contraction of the intestinal tube  probably causes in
this  case, also, a diminution of  its  calibre, but this form presents  no
peculiarity to distinguish it from the effect which may be  produced in
every case of catarrhal inflammation attended by repeated exacerbations.
(Vide p. 60.)
   The dysenteric process occurs  in its exquisite and primary form in the
colon only, Avith  the exception of the mucous membrane of the female
sexual organs, where it affects the uterine  mucous membrane in the shape
of the puerperal disease.
   The dysenteric process offers the  greatest analogy to the corrosion of
the  mucous membrane produced by a caustic acid.  The  consequent
destruction of the tissues, as  well as the phenomena  of reaction, present
throughout a close resemblance in both cases, and the stricture produced
in the oesophagus has no analogue but that resulting in the colon  from
the dysenteric affection.
   We have found a further analogy with  the dysenteric  process in the
erodent effect produced upon the mucous membrane of the oesophagus
by the gastric juice  in scirrhous stenosis of the pylorus.

Appendix.—The Non-typhous Intumescence of the Follicles and  Villi
                          of the Intestines.
   Although  the  intumescence of the intestinal  follicles occurring in
various morbid conditions is not the consequence of palpable inflammatory
action, it may yet be fairly considered at this place, as it commonly ap-
pears to result from the relation  of certain general morbid states to the
follicular apparatus.
   We find that the patches of  Peyer in the small intestine, the solitary
follicles of the small and large  intestine, and the follicles of Lieberkuhn,
in the small intestine, may be affected in this  manner.  The affection is
observed:

   1.  In substantive affections of the intestinal mucous membrane, as in
diarrhoea, and particularly when occurring in children, in whom  it is
marked by more  or  less vascularity  and congestion, but frequently also
by an anaemic condition of the parts.  In the diarrhoea of children and
young persons we find, besides an enlargement  of  the solitary and  of
Peyer's glands, a dilatation  of Lieberkiihn's follicles;  a grayish-white
creamy matter accumulates in their interior, Avhich  produces a whitish
punctiform appearance in the intestinal mucous membrane, or, in trans-
mitted light,  gives rise to so many opacities. 
78
ABNORMITIES  OF THE
  2. The affection  occurs most frequently as  a  reflex of constitutional
disease :  under these circumstances, the SAvellings of the solitary and of
Peyer's follicles are found principally in the colon in typhoid gastro-
enteric fevers, as an imperfectly-developed secondary typhous  eruption
in almost all the exanthemata, but especially in scarlet fever,  variola,
and erysipelas ; in acute rheumatism and gout; in croup; in suppurative
and gangrenous disease ; in febrile affections of the lymphatic glands in
scrofulous individuals ; in hydrocephalic fever; in a marked form in com-
mon Asiatic  cholera;  and  lastly,  in  acute  convulsions,  trismus,  and
tetanus.   The villi  are  generally also  much swollen, but we invariably
find the mesenteric  glands in a state of tumefaction.
  Swelling of the follicles is the consequence of a deposition of a grayish-
red, dull-white, or yelloAvish substance,  of  a lardaceous or  creamy and
glutinous consistence in the  cavity of the follicle,  accompanied by an
analogous infiltration of its parietes ; thus the follicle and the deposit not
unfrequently appear to constitute a homogeneous  body,  to Avhich the
term " granulations of the intestinal mucous membrane" has been applied.
This follicular affection differs from that occurring in typhus in everything
that characterizes the latter, and especially in reference to the metamor-
phosis of the typhous follicle.
  According to the predisposing  constitutional causes, the affection we
are treating of is more or less acute and transitory ; the deposit, the folli-
cular tissue,  and the mucous membrane in very rare  cases fuse into  a
small shalloAV ulcer; induration and a further  development  occasionally
take place, and the  mucous membrane being  pushed forwards,  a species
of polypoid pediculated groAvth is formed.

  3. Gangrene of the  mucous  membrane.—We have had occasion to
examine  the ulcerative process consequent upon inflammation in a variety
of forms, and any further investigation of  the subject were superfluous.
We pass  at once to  gangrene of the mucous membrane, although we must
observe that it rarely is a direct  consequence  of inflammation.
  Gangrene  of the  mucous membrane is brought on by compression and
traction,  and is generally accompanied by gangrene of the other intestinal
coats, as in incarcerated hernia at the point of strangulation, or in con-
sequence of excessive dilatation of a portion of intestine above a  stricture,
at various scattered points; it may occur in large patches in consequence
of mechanical hyperaemia brought on by incarceration, or of passive con-
gestion induced by  paralysis ; it may take place in the shape of  a circum-
scribed slough of the mucous membrane  consequent  upon  inflammatory
action  (gangrenous  inflammation strictly so called), in which the peculiar
anomalous state of  the blood and the peculiar  nature of the product  are
the cause of mortification.   To this head belong the sloughs of the intes-
tinal mucous membrane, which occur with symptoms of general adynamia
and putrescence, in acute dyscrasia  of the blood,  in purulent and ichorous
infection of  the  blood, under the form of degenerated typhus, cholera
typhus, &c.
  After  the  slough has become detached there is a loss of substance in
the mucous membrane which demands some attention, as it  may be con-
founded  with an intestinal  ulcer;  the diagnosis is  established by the 
INTESTINAL  CANAL.
79
 existence of an external or internal cause of gangrene, or by  a corre-
 spondence, in seat and form, between the latter and the external influence
 (compression, traction); again, the slough of gangrenous inflammation is
 distinguished by its  oblong, striated form, and very varying seat, by its
 defined contour, and  by the absence of morbid growth at the edge, at the
 base, as well as in the circumference of the eroded part.

   4. Inflammation of the submucous cellular  tissue.—In several of the
 processes Ave have hitherto considered, we have had occasion to notice
 the  various modes and degrees in which the submucous cellular tissue is
 im'ohred in disease of the mucous membrane.   An isolated inflammation
 of the submucous cellular tissue  is very rare, and when it does  occur  it
 is commonly metastatic and terminates in suppuration.   It takes place in
 the  shape of distinct foci of varying extent, which either give rise to per-
 foration of  the mucous membrane, or advance towards the peritoneum,
 and here produce peritonitis; or in  certain portions of the intestine, as
 in the caecum, colon ascendens, and rectum, produce extensive suppuration
 of the cellular tissue.

   5. Softening of the intestinal canal.—We may pass over the soften-
 ing  of  the intestinal  mucous membrane Avhich  Ave have described when
 treating of the Exudative Processes and  Dysentery,  as  converting the
 tissue into  a pulp, which, in proportion to the  state of vascular action,
 and to  the quality of  the exuding matters, is either easily removable or
 is spontaneously detached.   We have here to allude  to  the gelatinous
 ramollissement of the intestinal mucous membrane, Avhich offers  an
 analogue to the gelatinous softening of the gastric mucous membrane.  It
 is of much  rarer occurrence than the latter, though like this, it affects
 the small intestine as a complication of cerebral disease, of acidity in the
 primae viae, of extreme general collapse, atrophy of the muscular tissue, and
 anaemia of the intestine; it involves the external coats of the intestine,
 converts them into  a homogeneous, grayish-red, transparent,  and de-
 liquescent  gelatine,  and leads  to spontaneous  perforation.   We also
 advert to the analogue of black softening of the stomach, which occa-
 sionally, though  much more rarely, attacks the  intestine.   It occurs
 under the same conditions, and  mainly affects the mucous membrane of
 the caecum,  and in this case occurs, like  gelatinous softening,   on the
 cellular base of the typhous ulcer.

   6. Morbid growths  in the intestinal canal.—Under  this head Ave con-
 sider lipoma, the  formation of an anomalous, serous,  and fibro-serous
 tissue,  fibrous  and  fibro-cartilaginous tissue,  calcareous concretions,
 erectile tissue, tubercle, and scirrhus.
   a. Lipoma occurs of Ararious size in the shape of lobulated accumula-
 tions of fat in the submucous cellular tissue.  It forms rounded  tumors
 which are  invested by mucous membrane, project into the intestinal
 canal, and are sessile, or pediculated:  in the latter case they push the
mucous  membrane before them in the course of their  development, and
become  suspended by  a pedicle of mucous membrane.  Although pre- 
80
ABNORMITIES OF THE
senting a polypoid shape, they must be carefully distinguished from true
polypus.
  b. Anomalous serous and fibro-serous tissue occurs as a temporary or
permanent substitute  of loss of tissue in the mucous membrane, and in
very rare  cases in the shape of serous and fibro-serous cysts between the
intestinal coats.
  c. Fibrous and  fibro-cartilaginous  tissue  is found in the submucous
cellular tissue of the stomach, and less frequently, of the oesophagus ;  it
assumes the  shape of the  rounded or oval, flattened concretions;  of a
bluish-Avhite  color, and  elastic and firm consistence, which we have de-
scribed above.  They do not attain a greater size  than that of a lentil
or pea, and are freely movable under the mucous membrane.
  d. Chalky concretions more or less resembling bone,  though destitute
of its peculiar organization (so-called  ossifications), occur very rarely in
the intestinal canal.   If Ave sum up the results of the observations made
in reference to this point, taken in connection  with our incidental remarks
Avhen considering the diseases of the peritoneum, we arrive at the follow-
ing deductions :
  a. The  concretions  occur  as lamellae or  delicate  cords  in  the  sero-
fibrous tissue which is formed supplementary to a loss of mucous tissue;
  /?. As ossification of the  fibroid tissue occurring in the submucous and
subserous  cellular layers;
  y. As a loose chalky concretion or indurated calcareous pus between
the intestinal coats in sinuses accompanying catarrhal intestinal phthisis;
  5. As calcareous tubercle of the intestinal mucous membrane or the
peritoneum ;
  e. As ossification of peritoneal exudation on the intestine.
  e. Erectile tissue occurs as a pediculated polypus (mucous or cellular
polypus), or  in the shape  of large, broad, sessile  tumors,  chiefly  as a
consequence  of catarrh in  the colon  and rectum.   It  may in this case
also be the seat of medullary carcinotnatous infiltration.
  /. Tubercle.—The presence of tubercle in the tissue of the  intestinal
mucous membrane, and by extension, in  the deeper-seated coats, con-
stitutes a most important disease—tuberculosis  of  the  intestine in the
Avide, tuberculosis of the intestinal mucous membrane  in the  narrower
sense.   It may proceed to ulcerative  destruction, and this establishes
genuine intestinal phthisis.
  Amongst ourselves  this affection rarely occurs in the idiopathic form,
except during the first years  of life.  It is commonly the consequence of
pulmonary tuberculosis, and in the majority of cases, takes place after
the latter  has attained  the suppurative  stage (pulmonary phthisis), and
the general tubercular cachexia has become fully developed.
  The course it runs is frequently chronic, but much oftener acute : the
latter is more particularly the case Avhen it follows the tumultuous fusion
of numerous  pulmonary tubercles.  The tubercular deposit offers corre-
sponding  varieties in reference  to its original form, its  seat, and  its
metamorphosis.
  In the chronic affection  we find the mucous  membrane, and the adja-
cent layer of submucous cellular tissue, to be  the  original seat of the
tubercular deposit; there is no perceptible inflammatory action, and the 
INTESTINAL CANAL.
81
disease appears in the shape of the gray, transparent, tubercular granu-
lation,  which softens at its  centre,  and is gradually converted from
within outwards, into the yellow cheesy tubercle.  It seems blended Avith
the  mucous membrane, and  projects into  the  intestinal  cavity in  the
shape of a sessile, hard nodule.
   When the local appearance of tubercle takes place in the acute form,
there is considerable inflammatory action.    The deposit is effected simi-
larly to that occurring in the  pulmonary cells;  in the first instance it is
deposited in the cavity of Peyer's glands, then into  the solitary follicles,
and  lastly, in every  other part of the intestinal mucous tissue; it  appears
in large masses,  and in the  shape of yelloAV, cheesy  matter, which
speedily undergoes a purulent transformation.   The surrounding tissue
is found extensively congested, reddened and turgid; and when the de-
posit is excessive, the mucous membrane of an  entire  coil may be in a
state of congestion and irritation.   In this case tubercular tumors, either
scattered  over the surface of  the intestine or more  or less accumulated,
are found occupying Peyer's patches, offering  considerable projections
and  distinguishable through the mucous membrane by their yellow tinge.
   Tubercular deposit in the intestinal mucous membrane, being the re-
sult  of a fully-developed tubercular cachexia, commonly advances rapidly
to softening, and  this process is effected Avith  peculiar violence in  the
second variety.   The investing mucous membrane gives way at its most
elevated point, and  as the  orifice enlarges,  the suppurating tubercular
matter escapes.
   A cup-shaped ulcer, of the  size of a millet seed or a pea (the primary
tubercular ulcer) results ; its margin is firmly attached, rounded and in-
durated, and  of  a pale  or  red color in proportion to  the reaction that
occurs in  the  surrounding tissue; its base is either formed by the con-
densed submucous cellular  layer, or by the granulated  texture of  the
parietes of  the dilated follicle.   It  is only in very rare  cases that  the
tubercle fuses under the mucous membrane Avithout giving rise to per-
foration ;  it then forms at the expense of an inclosed  abscess, which
enlarges the submucous cellular tissue (vomica submucosa).
   The increase of the ulcer takes place  with more or less rapidity, it
loses its original form, but only to exchange it for a more characteristic
secondary one.
   The increase is effected by fusion of the tubercular infiltration of  the
margin of the ulcer, and by concurrent suppuration of the tissue.  In
the first instance, the small adjoining ulcers coalesce into one of larger
size; the  common base presents sinuous  projections of  the  common
margin of mucous tissue, ridges of mucous membrane may be seen  travers-
ing it in various directions, or even  solitary  insular remnants  of this
tissue are found upon it.
   If this process has occurred, as it does in  acute intestinal tuberculosis,
in one of Peyer's patches, the ulcer  may, on account of the elliptic form
prescribed by the shape of  the glandular  apparatus, be  mistaken for a
typhous ulcer, but we shall immediately point out that the peculiar re-
lations of the margin and the base afford a satisfactory clue to the diag-
nosis.
VOL. II.
6 
1    82
ABNORMITIES OF THE
   The ulcer, which is  formed by a  coalition of other smaller ulcers,
enlarges in the same  manner as the original solitary ulcer, in the direc-
tion of the intestinal  circumference, and at last  presents a  zone of
varying  Avidth  and uniformity.   Its  margin  is sinuous or dentated, in-
verted and  tumid, and is  formed by mucous membrane of a light red
color; from the  latter being infiltrated  Avith a transparent gelatinous
substance, an analogy is offered with the gelatinous infiltration occurring
in the vicinity of tubercular pulmonary abscesses.   The base is formed
by callous cellular tissue of a dirty Avhite color, underneath which the
remaining intestinal layers are found  similarly condensed and tumefied.
   Both in the marginal tissue and at  the  base we  find  a  deposition of
gray, or more commonly of soft, yellow, tubercular  matter.   The  ulcer
presents a very peculiar appearance,  on account of the remnants of mu-
cous membrane seen  on its base.  These adopt the characters of the
margin, and become  infiltrated with gelatinous  matter, so  as  to  form
crispated, transparent, condylomatous excrescences of a light-red color.
   In the same manner as the tubercular ulcer extends laterally, it may
advance in the opposite direction,  and thus giving  rise to perforation,
cause sudden death.   Secondary  deposition of tubercular  matter may
equally take place in  the callous cellular  tissue  of the  base, and  as it
fuses at this point, in the muscular and subserous layers also.   The peri-
toneum may become perforated in consequence of tubercular suppuration
being established in it, or in consequence  of mortification induced by the
approach of an abscess.  It follows that the tubercular ulcer perforates
the intestinal parietes without losing its original  character, inasmuch as
the progress of the tubercular affection is not arrested by an isolating
tissue ; in this it differs from the typhous ulcer, which does not perforate
the intestine in its original form, but affects the parts beyond  the sub-
mucous cellular tissue in its degenerated character.
   At an earlier or later period Ave find moderate inflammation attacking
points of the peritoneum which correspond in position to the intestinal
ulcer; a fibrinous exudation results, which is entirely, or in part, con-
verted into tubercle;  in the latter case it is  partly converted into cel-
lular tissue.   By the  intervention of this new product an  adhesion is
often effected at  the point of ulceration, between the  intestine and a
neighboring organ, e. g. the bladder,  the omentum, and  thus a more or
less substantial impediment is offered to the free discharge of the intes-
tinal contents into the peritoneal cavity on the occurrence of perforation.
   The mesenteric glands, lying in  the vicinity of  the affected portion of
the intestine,  are variously enlarged: in  the  primary intestinal tuber-
culosis of children they frequently attain the size of a walnut or  hen's
egg; they appear tuberculated  and pale, and present  a  deposition of
grayish, medullary, and hard, or  of yellow, grumous, and deliquescent,
tubercular matter.
   The small intestine is  the common  seat of intestinal tuberculosis
and in most cases the disease is limited  to this part;  still it often passes
on to the colon and descends to  the  rectum, or it ascends into the jeju-
num, and in very rare cases mounts to the duodenum and the stomach.
Sometimes it is much advanced in the colon  and then  appears to  have 
INTESTINAL CANAL.
83
been first developed  at  this point and subsequently to have  extended
to the small intestine.
   We may gather from the circumstances accompanying intestinal tuber-
culosis, that the further  it has  advanced the less a cure is to be hoped
for.   Still in the same manner as in the tubercular abscesses of the lungs,
we sometimes obcerve a healing process established in  a few  among a
large number of ulcers.  It takes place in the following manner.
   The first indispensable condition is the cessation of all secondary tuber-
cular infiltration at the margin or base of the ulcer; the callous base is
then condensed into a fibro-medullary cord, and the edges of  the  ulcer
approach one  another.  This process sometimes advances so far, that
the dentated edges almost touch,  and between  them  a  whitish,  cal-
lous cord may be observed.   Occasionally, the  edges  are  soldered  to-
gether over the callosity, yet so as to  leave a fissure at one  end of the
ulcer.   In very rare  cases an entire consolidation is effected.
   In consequence of  the contraction of the ulcer, a cicatrix forms on the
surface of the intestine, which  presents a more  or less elevated tumid
ridge on the internal surface of the intestine.  If the ulcer was of con-
siderable size,  or if  it encircled the entire intestine, a callous annular
ridge remains, which diminishes the  calibre  of  the intestine, and  when
viewed from without, occasionally gives rise to an appearance of  inva-
gination.
   Thus the cure of a tubercular intestinal ulcer  is always accompanied
by a diminution of the intestinal calibre.
   g.  Scirrhus, carcinoma of the intestine.—The carcinomatous affections
of the intestine, occur in the three  forms  of fibrous, areolar, and medul-
lary cancer, Avith and without the formation of pigment: two of these or
all three, may  be combined with one another, from their first  origin  or
consecutively.   The areolar form,  however is, at  least with us, of very
rare occurrence.
   The colon is almost exclusively the seat of cancerous degeneration, but
there is a gradation in the proclivity of its different sections to the  affec-
tion.   The rectum is most frequently  attacked, in second order the sig-
moid flexure, and the remaining portion  of the colon  but rarely.  The
small intestine is scarcely ever the  primary seat  of cancer ;  it is almost
always involved secondarily after adhesions have been effected with a
cancerous portion of the colon by means of peritoneal  exudation.  Me-
dullary carcinomatous cachexia, which is frequently acute and very exten-
sive, forms an exception, inasmuch as  it gives rise to a  medullary,  white
or colored infiltration of the mucous membrane of the small intestine and
its submucous  cellular tissue in the  patches  of Peyer.  If we except
this case, carcinoma occurs as a primary affection of the intestine in three
forms:
   Firstly, In  the  mucous membrane, as carcinomatous infiltration  of
the  erectile  tissue, into which the former has been previously  converted
—fungus;
   Secondly, More frequently in the submucous cellular tissue, as round
nodulated accumulations;
   Thirdly,  Most commonly as an annular deposit of the cancerous tissue
in the submucous cellular layer. 
84,
ABNORMITIES  OF  THE
  When the intestine is secondarily involved, it  is attacked  laterally,
and the disease  commonly proceeds from  the  lymphatic glands of the
mesentery, or from those of the lumbar plexus.
  A distinction of the two latter forms is of importance, in reference to
the observations that we are about to make.
  Here also, carcinoma  presents the Avell-known stages of  crudity  and
metamorphosis;  and we merely direct attention to this  again, because a
consideration  of the fact is absolutely necessary for a  complete exposi-
tion of cancerous intestinal stricture, which, next  to cancer  itself is of
extreme interest.
   Cancerous stricture of the intestine1 (Enterostenosis scirrhosa, cancer-
osa) is the  most common variety of stricture that results from altera-
tions in the intestinal coats, and at the same time the one that advances
to the highest degree; it also offers the first elements for  a rational theory
of ileus.
  We have already alluded to the tAvo main forms in which cancer affects
the intestine : it is either a narroAV  annular tumor surrounding the intes-
tine, the primary form,  which gives rise to annular stricture  ; or the in-
testine is secondarily affected by a propagation of the disease from neigh-
boring organs; in this case one side only may be involved to a consider-
able extent.   In  the latter case, however, the cancerous degeneration
may gradually extend over the entire circumference of the intestine, as
in the former the original annular stricture may extend upwards or down-
wards over a larger  portion of intestine.
  The annular stricture is commonly the most important; if the  morbid
growth continues in the crude stage, the calibre of the  intestine may be
reduced to the size of the little  finger, a  goose's or crow's  quill.   The
passage of the intestine is frequently much interfered with in the lateral
degeneration by protrusion of the morbid groAvth, but there is  generally
a corresponding dilatation of the  normal portion of the  parietes, and the
width of the tube is  thus not unfrequently found increased, even after the
morbid growth has enveloped the entire  circumference  of the intestine.
Although the former is by far the most dangerous,  and  soon  proves fatal
by ileus, this also follows sooner or later in the second case, notwithstand-
ing the existing dilatation.
   The metamorphosis of intestinal  cancer is of importance in reference
to the stricture, both in its first development and in its further progress;
it may render the stricture much more dangerous, or may lead to a cer-
tain improvement in the symptoms.   The turgescence that takes place in
the morbid growth at the commencement of the change, and the fungous
excrescences that arise on the surface of the intestine during its progress,
may render the stricture narrower,  and even induce perfect  occlusion of
the intestine.  On the other hand, the contraction may be relieved by
sloughing of the softened morbid growth, and  imminent ileus thus be
postponed.   The intestinal disease  may, unless  death ensue, as it often
does  from  exhaustion,  be  subsequently ameliorated  in various Avays.
After destruction of the morbid  groAvth, an ichorous cavity is left,  into
which the descending contents of the intestine pass and stagnate;  this
Oestr. Jahrb. xviii. 1. 
INTESTINAL CANAL.
85
condition is sometimes borne for a considerable period, provided there
is a sufficient discharge downwards.   In other cases ulcerative perfora-
tions  may  establish one  or more communications between the  portions
of intestine lying above and below the stricture, or ulcerative destruction
may take place in a different direction,  and give rise to artificial (vicari-
ous) anus ;  thus affording a hint as to the mode of cure to be adopted by
the medical man.
  The degenerated and  strictured portion of the intestine may remain
unattached, or become fixed.   The primary degeneration of the intestine,
exhibited in annular stricture, is commonly unattached, and it  then, in
proportion  as the diseased mass  increases, sinks to a lower region of the
abdominal  cavity.  This may,  in the  same manner as the scirrhous
pylorus, when it has descended  to the umbilical or hypogastric regions,
give rise to an error of diagnosis.  The dislocation is particularly liable
to present  an obstacle to the passage of the intestinal contents, if the
contracted portion is bent  at an acute angle, as occurs  in  the descent
of strictured portions of the transverse colon, or of the flexures of the
colon.
  The diseased portion of intestine  may be fixed, as is  the case in the
secondary  lateral degeneration of the intestine from its commencement;
the annular stricture may become attached in the same, or in a  different
manner.   In  the former case the intestine is either directly connected
with  the large lobulated morbid groAvths that extend to the glands of
the lumbar plexus, or even to the ligamentous appendages and the peri-
osteum of  the vertebrae (Lobstein's retroperitoneal groAvths), or it is at-
tached  to them by the intervention of a cord or peduncle which passes
through the mesentery.   In consequence of the partial  contraction of
the tissues, and  especially of the intestinal coats,  and of the  unequal
distribution of the morbid growth, the  degenerated portion  of  the tube
is more or  less inflected.
  The annular  stricture, which in the first instance is unattached, may,
as the cancer advances, become  fixed in a similar manner at the point
of its original development, or at different parts at a distance from  this
point,  either by cellular tissue, or   by a fusion of the  carcinomatous
tissues.   The  propulsion of the  intestinal contents will, in that case, be
impeded to a greater degree than in simple dislocation,  and the more
so, the greater the dislocation itself, the more acute the angle of inflec-
tion, and the more firm the adhesions are.
  The intestine lying above the diseased portion is found affected to a
various extent, and commonly in proportion to the amount  of  contrac-
tion, by active dilatation, i. e., dilatation accompanied by hypertrophy
of the muscular coat.   The parietes  of this section of the intestine are
occasionally found very  much thickened and indurated;  the muscular
coat presents  a yellow discoloration  and is friable, the  cellular layers
are infiltrated Avith a  gelatinous medullary  substance, the mucous mem-
brane is thinned  and resembles a serous membrane, and  the contents of
the intestine  accumulate to a  considerable  extent above  the  affected
point.   The portion of intestine which  lies  below the cancerous mass is
more or less permanently contracted  and empty.
  In  considering the metamorphosis of intestinal scirrhus, we have ad- 
86
ABNORMITIES  OF  THE
  verted to its terminations ; it commonly ends fatally Avith symptoms of
  intestinal inflammation and ileus.
    . Cancerous ulceration, more frequently than any other variety of ul-
  ceration, gives rise to communications between the affected portion of
  intestine and  neighboring  cavities and passages,  and more especially
  with the rectum.
     Intestinal carcinoma often occurs in the isolated form, but it is  not
  unfrequently complicated with  cancer of the stomach,  the liver,  the
  lymphatic glands, and the bones, with osteomalacia, and universal can-
  cerous cachexia.
     There  are certain  ulcers which occur only in the large intestine, and
  especially in the sigmoid flexure  and the rectum, and  are nearly allied
  to cancer, and particularly to cutaneous cancer.  They are  generally
  solitary, but there may be  tAvo, three, or four at a time.   They inva-
  riably give rise to intense pain,  and appear etiologically  connected with
  an abuse of ardent spirits.   Although in many respects analogous to
  the ulcers hitherto considered, they offer distinctive characters.   They
  are invariably zonular and have a callous base, upon which  occasionally
  a discolored, brownish, grumous  discharge is visible, and they are sur-
  rounded,  by a  thick, tumid, spongy,  carneous, and irregularly-sinuous
  margin of mucous membrane.   They generally cause a diminution of
  the capacity of the intestine, though not to any considerable degree.  A
  further investigation into their nature still remains a desideratum.

     7.  Theory of the ileus produced by cancerous degeneration of the in-
  testine.—Independent of the degree of stricture, the degenerated portion
  of the intestine, owing  to  the adventitious groAvth  deposited in the sub-
  mucous tissue, and still more from the consequent disorganization of the
  muscular coat, is in  a completely passive condition.   The propulsion of
  the  faeces through this portion is  therefore  effected  by the muscular
  activity of the higher part of the intestine,  even when the lateral posi-
  tion of the disease allows of dilatation.   The more  considerable the
  stricture, or the more  extensive  the  growth, and  the  more copious the
  feculent accumulation, the more will this activity be called into play.
     The contents of the intestine  necessarily stagnate and accumulate in
  that portion which lies immediately above  the diseased point, and dilate
  it.  If the dilatation is effected suddenly,  paralysis  at once  ensues;
  otherwise the  accumulated masses, a certain portion of which are only
  propelled through the degenerated section of  the  intestine, give rise to
  reaction, hypertrophy of the membranes follows, and as  these influences
  increase, gradual exhaustion and  paralysis result.  This paralyzed por-
  tion of intestine is  the proximate cause of the supervening ileus.  As
  soon as the faeces have accumulated  within it to  such an  extent as to
  reach the adjacent sound portion of intestine, the latter undertakes their
  discharge.  Its capability of effecting this  will diminish in proportion
  to the  amount of accumulation, and to the contraction of  the stricture.
  The consequence is, that the peristaltic action is reversed,  and  that the
  antiperistaltic movement conveys the  intestinal contents  to the stomach
  from which they are ejected by vomiting.
     The coexistent intestinal inflammation, which  commonly  occurs as
_/ general peritonitis,  also has a  share  in the process.   It commences at 
INTESTINAL CANAL.
87
that point immediately above the stricture, which has become most di-
lated by the accumulated contents, and it is there most  intense.  This
portion of intestine presents a dark-blue or blackish-red discoloration,
with a tinge of brown or green; its coats are infiltrated with blood ; the
peritoneal investment, which is covered with a dirty-green or brownish
exudation, is easily detached; the muscular coat is discolored and friable;
the mucous  membrane, owing to its distension, is devoid of  plicae, villi,
or follicles;  dark-red, distended at some parts with coagula, and sloughy.
Sometimes all  the intestinal coats are perforated at these points, and
there is consequently an extravasation of the intestinal contents into the
abdominal cavity.
   The inflammation extends from this portion  of the intestine upwards,
and is followed, pari passu, by paralysis.  It  passes from the  intestine
to the mesenteries, to the omentum, and  to the parietal  laminae of the
peritoneum.
   In  some cases the inflammation is the result of irritation existing in
the morbid product, which  is transferred to the peritoneum, and causes
paralysis  of  the muscular coat above the stricture, dilatation of the in-
testine and ileus.
   It follows that, to appreciate the causes of ileus arising from scirrhous
strictures of the intestine correctly, we must take into consideration :
   Firstly; the  absolute degree of stricture.
   Secondly; the degree of attachment of the affected portion of intes-
tine, Avith or without dislocation and inflection.
   Thirdly ;  the degree of the consecutive affection of the part above the
stricture.
   Fourthly; the degree of the inflammation present.

   Appendix.—Biseases of Separate Sections of the Intestinal Canal.

   Separate sections of the intestine demand special attention,  inasmuch
as not only  many diseases occur more frequently at  one part than at
another, and are subject to numerous modifications in reference to their
issue  and result, but as many diseases exclusively affect one portion of
the intestine.  We shall consider the diseases of the duodenum, of the
caecum and vermicular process, and of the rectum, separately, on account
of their peculiar importance.

   a. Biseases of the duodenum.—We frequently meet Avith cellular ad-
hesions between the upper  transverse portion of the duodenum and the
concave surface of the liver and the gall-bladder.
   The mucous membrane of the duodenum not unfrequently bulges out
through the muscular coat in  the shape of a  hernial  diverticulum, an
occurrence which is undoubtedly favored by the absence of the peritoneal
investment.
   Catarrhal  irritation, and even inflammation, undoubtedly often affect
the duodenal mucous  membrane, and are frequently  induced by an
anomalous condition of the bile.  It appears that they may extend to the
biliary ducts, and induce icteric symptoms by a retention  of the  bile
(Stokes).  We  often find evidence of chronic  catarrh or blennorrhoea of 
88
ABNORMITIES  OF  THE
the mucous membrane in the dead subject, accompanied by brownish-red
or slate-gray discoloration, by hypertrophy of the mucous membrane and
Brunner's glands, and by the formation of polypi.
   As regards ulcerative processes, Ave find, besides tubercular ulcer, which
is very rare, the perforating ulcer occurring at the upper transverse por-
tion (vide perforating gastric ulcer), and perforation resulting from an
extension of the process from the gall-bladder to the duodenum.
   Carcinoma  very seldom occurs in any shape as a primary affection of
the duodenum; it  is sometimes  secondarily attacked posteriorly by^ an
extension of the disease from the  cancerous lymphatic glands surrounding
the head of the pancreas and the gall-ducts.

   b. Biseases  of the caecum and the vermicular process.—The caecum
and the  vermicular process are  occasionally absent, or are only imper-
fectly  developed;  in  some cases the former has been found fissured
(Fleischmann).
   Anomalies in the position of the caecum are confined to its position on
the left side  in lateral dislocation of the  abdominal viscera, and  to its
position in large inguinal or umbilical hernia.  Its attachments are some-
times very loose,  and this appears to result from  repeated dilatation.
   Catarrhal inflammation of the  caecal mucous membrane is remarkable
on account of the frequency of its occurrence, and that form which is oc-
casioned by habitual constipation, so-called typhlitis stercoralis, is pecu-
liarly characteristic.   It chiefly  originates in  sedentary habits, indiges-
tible food, and rheumatism of the  muscular coat.   The symptoms are
those of catarrhal  inflammation  generally;  it runs  an acute  course, is
subject to frequent relapses and degenerates into the chronic form.  Re-
moval  of the  accumulated  pus, and avoidance of fresh accumulations,
generally suffice to establish a cure.  If this is not effected, ulcerative
destruction of the mucous membrane, and continued sinuous suppuration
of the muscular coat, result.   In  this manner rapid perforation of the in-
testinal parietes, and especially of the posterior  side, may  follow, either
inducing extensive inflammation, ichorous destruction  of the cellular
tissue in the iliac and lumbar regions  and death ; or giving rise to general
peritonitis, in  consequence of  the destructive process passing from the
right iliac region in a different direction.
   In the chronic  form the cellular tissue at the posterior surface of the
intestine condenses, and the adjoining muscular coat and the entire caecum
shrivel up; on cessation of the  ulcerative process, the  caecum is found
converted into a slate-colored capsule, with dense parietes, of  the size of
a walnut or a pigeon's egg; in  the place of the mucous membrane there is
a sero-fibrous, retiform and trabecular tissue.
   In reference to the  caecum Ave observe, that the inflammation of the
loose, stringy, cellular tissue  external to the iliac fascia (perityphlitis),
is of considerable  importance.   It  is occasionally idiopathic, but more
frequently metastatic; it is very dangerous, both on account of the facility
with Avhich the pus spreads, and on account of the perforation  of the
caecal parietes which may ensue, and the consequent extravasation of in-
testinal contents into the seat  of inflammation.
   The vermicular process is sometimes reduced to a mere  cellular sinus 
INTESTINAL  CANAL.
89
of the caecum; it varies in size from that of an insignificant nodule to five
or six inches.
   There are considerable variations in the position of the caecum.
   Adhesions of its free extremity may become a matter of importance
forming rings or fissures in which the intestine is strangulated.
   Catarrhal inflammation of the vermicular process is a disease of common
occurrence, and very dangerous  on account of its consequences.  It much
resembles typhlitis stercoralis, and  is invariably the result of fgecal mat-
ters and  foreign  bodies, especially  small  fruit-stones, having  become
lodged and hardened in it.
   The affection has  a torpid character, may exist for a long period as
blennorrhoea, and is accompanied by thickening of the coat of the vermi-
cular process.   After frequent  exacerbations it passes into  ulceration,
Avhich may, if the foreign body remains loose, attack the entire process,
or if the former becomes fixed, affect only the point of attachment, or the
vermicular process.   In  the second case, the  constant irritation at one
spot, or the accumulation of ulcerative secretion and the  consequent dis-
tension, induce a rapid development of the morbid process.
   Under  favorable circumstances, especially if the  foreign body is dis-
charged, the ulceration terminates, and the vermicular process partially
or entirely shrivels up and forms a lead- or slate-colored ligamentous ap-
pendix.
   In the  opposite case the ulceration, especially when gangrene is super-
induced, more or  less speedily brings  on perforation  of the  vermicular
process ;  this may occur at various points, sometimes at or near the ter-
mination, sometimes at the  circumference, in such a manner as to cause
a division into two parts.   This perforation and the consequent discharge
of the purulent contents into the peritoneal cavity,  are not immediately
followed by general peritonitis,  inasmuch as the previous irritation has
induced adhesions with  the  neighboring peritoneal folds, which  render
the ultimate perforation  innocucous for a time, as far  as regards the re-
mainder of the peritoneum.  In the interior of the circumscribed cavity
the ulcerative process in the mean while continues, the adhesions gradu-
ally give way, and general peritonitis ensues.
   We further  occasionally observe  a metamorphosis  of the  vermicular
process produced  by obturation,  which is analogous to dropsy of  the ef-
ferent ducts of glands, and which  is most apparent in  the gall-bladder
(hydrops cystidis felleae).   The foreign body sometimes attaches itself to
a certain point and closes the canal without inducing ulceration; in con-
sequence of an accumulation of the mucous secretion the vermicular pro-
cess dilates, the mucous membrane  thins and is gradually converted into
a serous membrane which secretes an albuminous fluid.   The vermicular
process is thus metamorphosed into an hydropic capsule, which in the
course of time certainly may become the seat of inflammation, resulting
in ulceration and perforation.
   Typhous and tuberculosis affections frequently extend to the vermicular
process, and both may be followed by perforation.
   c. Biseases of the rectum.—The main defect of development to which
the rectum is liable, is that represented by atresia ani, or congenital oc-
clusion of the anus.   In this case the rectum either has  a blind termina- 
90
ABNORMITIES OF THE
tion, is absent, or  opens into the urinary and  genital passages (cloaca).
In the first case the rectum may reach down to the point Avhere the_ orifice
should be, but the orifice is closed by an expansion of the common integu-
ments  over it; these are distended by an effort at defecation, and the
meconium may even be seen through them.   There  may however be a
greater deficiency  of the rectum, the latter terminating at a higher point,
or it may be  totally absent, and its place be occupied by dense cellular
tissue.   In these cases the pelvis appears in an undeveloped state,  espe-
cially in its antero-posterior diameter;  it  is very much inclined, and the
external genital organs are placed very far back. This affords a valuable
aid in the diagnosis, as it allows us to infer a considerable deficiency in
the rectum.
  Anomalies in the calibre of the rectum are both frequent and important,
and appear in the  form of dilatations or contractions.  The former attain
a very considerable extent, presenting sacculated sinuses, and an accumu-
lation of indurated faeces; they are accompanied by considerable thicken-
ing of  the  coats  and blennorrhoea.   The latter vary much in form and
distribution, but more  still in respect of  their  causation.  In the first
place, the rectum is more  liable than any other portion of intestine  to be
compressed  by neighboring viscera, by the pregnant uterus, by tumors
developed in  the uterine or vaginal parietes,  by diseased ovaries, the re-
troverted uterus, the hypertrophied prostate, vesical calculi, pessaries, &c.
The contractions dependent upon disease of the  coats of the rectum are of
still greater importance.   To these belong contractions from hypertrophy
of the coats, accompanied by an accumulation of fat, and induration of
the surrounding cellular tissue; contraction  consequent upon  catarrhal
inflammation and suppuration, or gonorrhoeal ulcer ; contraction resulting
from a dysenteric  cicatrix, polypous tumors, and various forms of cancer.
Of these the strictures  consequent upon  dysentery and cancer are the
most important.
   Hypertrophy of the sphincter is a remarkable affection; it may in rare
cases, especially in children, give rise to obstinate constipation and even
ileus, but it  frequently induces excoriation of the mucous membrane, the
so-called fissure of the rectum.
   We have already (p. 56) discussed prolapsus ani.
   Catarrh  and blennorrhoea, accompanied by hypertrophy of the coats,
which frequently gives rise to plicated and polypous excrescences of the
mucous membrane, are very frequent affections of  the rectum.   Gonor-
rhoeal catarrh of the rectum represents a  peculiar variety:  it affects the
same uniformly, or in a circumscribed spot:  in the former case it is fol-
lowed by a shrivelling of the  rectum, and the mucous  membrane gra-
dually disappears; in the latter by a callous induration of  the coats of
the rectum, and  not unfrequently by the formation  of  an  ulcer, which
as well as the stricture is  placed in the vicinity of the sphincters, and is
distinguished by its zonular form, its sinuous circumference, and its cal-
lous puckered base.
   The hemorrhoidal ulcer is peculiar to the rectum.   It results from the
irritation of  the  mucous  membrane,  produced by  lasting congestion in
inversion and prolapsus, strangulation by the sphincters, compression of
the hemorrhoidal swellings, and undue  medicinal interference.   It  is 
INTESTINAL CANAL.
91
distinguished by its seat in the vicinity of the sphincters, its irregular
shape, its indented and sinuous flabby margin of mucous membrane, and
the similar ridges of mucous membrane  that  surround or  pass over it.
On account of  the  absence of reaction in the parts,  corrosion of the
vessels not unfrequently brings on violent hemorrhage.
  An inflammation of cellular tissue resembling perityphlitis, occurs in
the rectum, as periproctitis.  The remarks made in reference to the
former  apply to the latter also  (vide p. 88).   It occasionally becomes
chronic, and thus induces  hypertrophy and callosity of  the cellular and
adipose tissues surrounding the  rectum,  which however differ from the
analogous result of cancer.  Like the hemorrhoidal ulcer,  it may cause
fistula recti.
  Of intestinal  cancerous  affections, those occurring in the rectum are
the most  frequent, especially if  we include the scirrhous degenerations
Avhich involve it by extension from the female  sexual organs, but which
we do not allude to at present.
  Cancerous disease attacks  the rectum in the various  forms above de-
scribed as affecting the intestine at large.   The  folloAving however are
particularly remarkable:
  a. Erectile tumors  developed  in the tissue of the  mucous membrane,
and infiltrated  with medullary  carcinoma;  they  assume  the shape of
broad, sessile, or pediculated fungi.   They are commonly placed at the
commencement  and posterior surface of the rectum, at about three or
four inches from the orifice; we  find  these excrescences only in excep-
tional cases, at or close to  the sphincters.
  /?. Annular carcinoma and stricture of the rectum.  It occurs almost
exclusively at the  upper portion of the  rectum,  and especially at the
point at which the sigmoid flexure  terminates in the rectum, and which,
in its normal condition, presents a  distinct  contraction.   The  strictured
part is either unattached, or, as is more commonly the case, firmly agglu-
tinated laterally to the promontory; notwithstanding its elevated position,
it is, as Cruveilhier correctly remarks, pushed down by the feculent accu-
mulations above, which  generally precede  the  occurrence  of ileus, it is
therefore easily reached in exploring with the finger.
  y. Scirrhous  degeneration of the  rectum over  a large surface, or
throughout its entire extent.—This  primarily affects the submucous cel-
lular tissue, from which it  extends through the entire muscular coat to
the cellular sheath of the intestine, the cellular and adipose tissue of the
pelvic  cavity, to the posterior surface of the  vagina, and  even to the
uterus; or it originally attacks one of the last-named tissues, and involves
the rectum secondarily.   The rectum is firmly  attached, from  being
agglutinated in its entire extent to the sacrum, or adherent to the vagina,
or it appears wedged into the pelvis by the surrounding  morbid growth;
its  calibre may be variously diminished,  though  it  sometimes is unal-
tered ; its internal  surface is uneven, nodulated, and hard,  or it is filled
with soft, fungous, bleeding growths;  the anus, especially if the morbid
product extends to  the sphincters, is patent, everted, and varicose; even
the perineum appears more or less swollen, protruded, and  hardened;
and this  induration extends to a considerable  extent over the nates in
consequence of  the condensation of the subcutaneous adipose tissue. 
92
ABNORMITIES OF THE
   The foreign bodies found in the rectum  may either have reached it
from  above,  but  not proving injurious until  they reach this  point, or
they may have been introduced, per anum, in consequence of  morbid
sensations or perverted  sexual  desire.   In the latter case they are com-
monly very singular objects and of alarming size.

   § 6. Anomalies of the Intestinal  Contents.—1.  ExcessiA^e accumula-
tion of gas is very frequently caused by an increase in the  secretion on
the internal  surface of  the intestine, accompanied by  an impediment to
its escape.   This occurs over a large extent of intestine in morbid affec-
tions of the mucous membrane,  and especially in the exudative processes,
such as typhus, in the  shape of tympanitis; the escape of the gas  is
impeded by the paralyzed  state of the  muscular coat.  This condition
also  accompanies  anomalous states of other intestinal secretions, espe-
cially of the  intestinal mucus,  or morbid affections of the nervous, espe-
cially the ganglionic, system; in the latter instance,  however,  there is
frequently no increase in the amount of gas  secreted, but in  consequence
of the atony of one portion of intestine,  and spasmodic contraction of
the remainder, or of atony of the entire tube, it  accumulates, and  is
retained in the shape of tympanitis throughout the canal.
  Occasionally, an  excessive accumulation of gas is brought on by the
consumption of certain  flatulent articles of  diet in a debilitated state of
digestion, or where there is an  absence of the due amount of bile.
  2. The intestinal mucus is very often found in excess, and occasionally
the amount secreted is insufficient:  in the former case, it also undergoes
considerable modifications as to quality.   The increase of secretion either
exists  throughout the intestinal canal, or affects certain sections in the
shape of chronic  catarrh or blennorrhoea;  the mucus is either milky,
Avhite, yellowish and purulent, or glutinous, transparent, vitreous, spaAvny.
In the congestive state of typhous and typhoid diseases, we find a pecu-
liar gelatinous  mucus on the  intestinal mucous membrane, and more
especially on that of the small  intestine and caecum.
  A diminution in the quantity of mucus  accompanies excessi\re forma-
tion of bile and of  feculent matter (copropoesis).
  3. There can be no doubt that  a peculiar gelatinous constitution of
the mucus is the nidus of  intestinal  entozoa, and  the cause of helmin-
thiasis.  There are two orders of worms, the nematoidea  and the  ces-
toidea: to the former belong the ascaris lumbricoides, the trichocephalus
dispar, and the oxyuris vermicularis;  to the latter, the taenia solium and
the botryocephalus dispar.
  The lumbricus occurs in the small intestine of children and young
persons, and is sometimes found in large numbers, forming knotted accu-
mulations.  It  often ascends to the  stomach, into the oesophagus  and
pharynx, it may eA'en pass from here into the larynx, and  thus, as has
been distinctly observed, produce suffocation.   Occasionally, several lum-
brici may be  found undertaking such and similar preposterous peregri-
nations at the same time.
  The trichocephalus dispar inhabits the  caecum and the adjoinino- por-
tion of the small intestine.   Its occurrence in  the  gelatinous  feculent
contents of these parts in typhus, is very important. 
INTESTINAL  CANAL.
93
   The oxyuris (ascaris) vermicularis inhabits the rectum.
   The taenia is found, one or more in number, in the small intestine.
   We may still be permitted to doubt the fact that the entozoa ever per-
forate the  intestine, at all events, it is a very rare occurrence.  It is well
established, hoAvever, nor is it of very unus.ual occurrence, and this applies
especially  to the lumbricus, that they pass  through orifices in the intes-
tinal parietes into the abdominal cavity, into abscesses, into the bladder
or the vagina.
   4.  The faecal matters offer various important points for consideration.
   They  sometimes  accumulate  in the  intestine  to  an  extraordinary
degree,  in  consequence of repletion, torpor of the intestine, diminution
of the intestinal secretion, increase of the absorbent powers of the intes-
tine,  and  induration of the faeces.  These accumulations  occasionally
affect single portions of  the intestine,  and  may, if  persistent, induce
disease  of  the coats.
   The occurrence of an excessive elimination of faeces (copropoesis exce-
dens) from the intestinal secretions, is an established fact.  It takes place
as a critical  discharge in  various diseases,  and especially in  those that
are accompanied by increased secretion in the intestinal canal;  but recent
observations have  demonstrated its occurrence as an  idiopathic  disease,
which may, by the excessive drain it causes, give rise to atrophy of the
intestinal  coats and to  general emaciation.   The color  of  the  faeces
mainly  depends  upon the color  and degree of saturation of the bile.
They may be dark-brown, dark-green,  black, pitchy, or, in the absence
of bile, grayish or clayey.   Occasionally the faecal discharge is brown
internally, and invested by a white clayey covering, of varying thickness.
   The consistency of the faeces varies considerably : they are liquid when
the serous exhalation of the mucous membrane is excessive; semifluid
when the secretion is muco-gelatinous; or they are mixed, with the secre-
tion in the shape of flocculent grumous particles.   The feculent matter
found above  the various intestinal  strictures presents a peculiar frothy
appearance.
   The faeces may have hardened, so as  to  present lumps or scybala of
various  sizes.  This  scybalous  induration generally takes  place in the
sigmoid  flexure and  the  rectum,  though it occasionally reaches  up to
the caecal valve.   If accompanied by flatulency, small portions  of fecu-
lent matter are found to adhere to the intestine, and after the mucus by
which they were made to adhere has dried  up, they appear agglutinated
to, and  even imbedded in, the internal surface of the  intestine.
   Figured faeces either form cylinders, which may be  variously affected
by pressure of the intestine or by stricture,  or they form tubers of various
size.  This leads  us  to a consideration of  faecal concretions  and intes-
tinal  calculus.
   5.  Intestinal concretions are  either formed in the  intestine,  or after
being formed external to it, reach it by  the  natural or  by abnormal
passages.
   To the former belong indurated scybala, which may be produced under
all the circumstances that give  rise to a retention of faeces;  and espe-
cially the tuberculated faecal concretions that form in  and  adhere to the
cavity of colonic diverticula.  They may be various foreign bodies, such 
94
ABNORMITIES OF THE
as fruit-stones, indigestible portions of vegetables or pieces of bone, Avhich
have been introduced into the intestine, and become incrusted Avith faecal
matter.  Or such bodies, especially when occupying a blennorrhoic por-
tion of intestine, as the vermicular process or caecum, give rise to deposits
of grayish fatty matters,  chalky and saline substances.
   To the latter belong biliary calculi, which have reached the  intestine
by the natural passages,  or by ulcerative communication; and  the fatty
and  chalky concretions which have  formed  in  abscesses adjoining the
intestine and have passed into the latter.
   Intestinal concretions prove injurious to the intestine, in proportion to
their size and form, as we shall have occasion to explain further on.
   With regard to serous, muco-serous, albuminous, puriform, and puru-
lent discharges, to fibrinous coagula, and pseudo-membranous formations
in the intestine, Ave refer to the remarks given under these heads.
   6. Blood is found in large  or small quantities,  coagulated and fluid,
red or variously discolored, in the vicinity of the  point at which it was
discharged, or extended  over a large surface.  Hemorrhage occurs in
consequence—
   Firstly;  Of active, passive, and especially of mechanical hyperaemia;
the latter being a  frequent  result of obstacles in  the portal system.
The mucous membrane presents no essential textural alterations, but  is
either congested and suffused, or in consequence of the excessive hemor-
rhage, pale and anaemic.   The source of hemorrhage is scarcely disco-
verable.  We have lately seen tAvo remarkable cases of this description,
in which exhausting hemorrhage  resulted from intense and extensive
burns of the abdomen.
   Secondly; In consequence of the  various exudative processes accom-
panied by solution of the mucous tissue and its vessels, e. g. in dysentery.
   Thirdly;  The hemorrhage  may be caused by other morbid  degenera-
tions of the mucous tissue, e. g. erectile fungoid excrescences, the typhous
deposit at the period of metamorphosis, or torpid ulcers.
   Fourthly; In rare cases the hemorrhage results from the rupture of a
varicose vein in the submucous tissue of the intestine, the investing mu-
cous membrane giving way at the same  time.  It  is more frequently
caused by corrosion of an artery or vein at the base of a hemorrhoidal
ulcer of the rectum.
   Every variety of hemorrhage, but  especially the one first  cited,  is
favored by diminished density of the blood.
   When the blood is found  extravasated  over  a  large  surface, it  may
have come  from above, but it frequently happens that the source of the
hemorrhage is below the  extravasation; this  is  particularly the case  in
hemorrhage of the rectum.
   Moreover, the blood may have reached the intestine from the stomach,
the oesophagus, the hepatic viscera, and even from the respiratory organs.
   The longer the blood remains  in the intestine, the longer it  has  been
exposed to the operation of the intestinal  secretions, the more it becomes
discolored, assuming a chocolate  or  black tinge;  and when it has ex-
perienced the influence of the gastric juice, it is  frequently  converted
into a pitchy or tarry mass.   Bile in a  very concentrated form often
presents a similar appearance. 
INTESTINAL CANAL.                    95
   The intestine sometimes offers a passage by Avhich acephalo-cysts  of
the liver (the so-called hydatids) are discharged.
   7.  We must lastly investigate the foreign bodies found in the intestine.
   To this class belong concretions formed within the  body, and especi-
ally in the biliary ducts, and substances that have been introduced by
mouth or per anum.  They prove injurious by producing lesions of the
intestinal parietes, as in the case of rough  or  pointed bodies, bones  or
fragments of  bone, portions of  stone, glass, needles,  &c.   After attach-
ing themselves to the mucous membrane,  suppuration is established, and
they may thus escape through the intestinal and abdominal parietes;  or
the perforation may communicate Avith  another portion of intestine,  or
with a neighboring hollow organ, and the escape be effected through the
urinary and genital organs.  The foreign bodies may also block up the
intestine and induce ileus; these cases are  of  extreme importance, and
they admit of the following subdivision :
   Firstly,  The foreign body is  arrested at a certain point of  the intes-
tine, in consequence of its rough and angular form.
   Secondly,  the foreign  body is retained simply from  a disproportion
between the calibre of the intestine and the size  of the substance, and
occlusion is the result.
   Thirdly, The foreign bodies accumulate to a considerable  number  at
one point, and the consequent extreme dilatation and paralysis of the in-
testine induce obstruction.
   Rough, angular bodies, if not very large, frequently pass through the
intestine without difficulty, in an envelope of mucous and  feculent mat-
ter ;  but they often become attached to the intestine, by inserting their
edges and processes into it, and may, by the  consequent inflammatory
swelling, give rise to an  obliteration of the  passage.
   Large round or oval bodies, with a smooth surface, may be retained at
various points of the small intestine, but especially at the  terminal  por-
tion of the ileum, Avhich presents a distinct diminution in calibre.
   We class among these foreign bodies large biliary  calculi, which have
escaped from the bile-ducts into the intestine.
   Indigestible substances that have been  taken in large quantities, espe-
cially the peel of fruit, cherry, and plum stones, often accumulate  at
particular points  of  the  colon, as the caecum or the  sigmoid flexure.
They give rise to uniform or lateral dilatation of the  intestine, accom-
panied by atony and paralysis of the latter.  This condition may, sooner
or  later, in a ratio with the size  of  the accumulated mass,  give  rise
to ileus ; or if the accumulation is inconsiderable,  and the action of the
superior portion of the intestine capable of  effecting a partial discharge,
it may last a considerable time,  and end in a cure ; or it results in chronic       ^
inflammation, the formation of sinuses,  and the ultimate  contraction  of
the intestine, which again may  give rise to occlusion.

                 Appendix.—On spontaneous Ileus.

   We distinguish between the so-called organic ileus, into the  nature  of
which we have inquired in  preceding paragraphs, and dynamic or spon-
taneous ileus.  The latter deserves a careful investigation  of  its cada- 
96       ABNORMITIES  OF THE  INTESTINAL CANAL.
        veric relations, the more so as a sound theory of its nature, based upon
        practical experience, is very much Avanted.
          Ileus is a rare occurrence, and undoubtedly often  dependent upon
        atony of an intestinal segment, which must be vieAved as  the proximate
        cause, in contradistinction to the case just examined, in which the accu-
        mulation of foreign matter is the primary affection.  It takes its origin
        in a sedentary mode of life,  in depressing physical conditions, repletion,
        superstimulation by purgatives and injections, rheumatic affection of the
        intestine, diseases of the spinal cord, and even of the brain.  The colon
        is the part almost invariably affected.  Stagnation  and  accumulation of
        the fasces in the affected portion of intestine folloAV, dilatation is induced,
        and the atony ends in paralysis ; Avhen this  happens, ileus is  at hand.
        Its actual occurrence, however, as Avell as the improvement and  cure of
        the affection, depend upon the state of innervation in the  upper healthy
        portions of intestine.  If the action of these portions suffices to propel
        the faeces through the dilated segment, and thus from to time to empty
        it, the latter may resume its functions, and thus return to  a healthy con-
        dition.   If, however, the upper portion of the intestine does not possess
        sufficient poAver, which will be the case if the accumulation be excessive,
        or the paralyzed segment has  sunk to a  lower  region of the abdomen,
        the accumulation  will proceed, and at last reach up to the healthy intes-
        tine.   Here the peristaltic action is reversed, the faeces are thrown back
        into the stomach,  and are expelled from there by vomiting.
          When the paralysis  has  reached a certain point, inflammation  and
        sloughing  set  in, and enteritis peritonealis results.   As this  induces
        paralysis of the muscular coat and passive dilatation in the upper portion
        of the intestine, a change occurs in  the  ileus, inasmuch as the  point at
        which it commences advances with the advance of the inflammation.
          All pathologists of distinction deny the possibility of spasmodic con-
        traction or spasmodic stricture in a portion of the intestine, being  the
        cause of obstinate constipation or of ileus.   The modus operandi of the
        various remedial agents  employed fully confirms the theory given with
        regard to this simple form of ileus.   The  benefit  derived from purgatives
        is to  be explained by the force with which the healthy intestine propels
        the faeces  downwards, and the rapidity with which they pass  through
        the distended portion ; the advantage of  opiates consists  in diminishing
        the activity of the healthy portion, and the consequent accumulation in
        the dilated part, and in  allowing the latter time to recover its activity.
          It  is highly probable  that the use of narcotic  enemata of tobacco or
        belladonna, effects an evacuation of the dilated portion, by inducing a
        complete relaxation in  the  inferior portion  of intestine,  which is  thus
#       enabled to  admit  and convey onwards the accumulated faeces.   If the
        injected fluid can  be propelled as far as the diseased part, the discharge
        of the  faeces is aided by the mechanical distension  of the intestine  and
        is undoubtedly further promoted by the change of position which the in-
        jection effects in the healthy  intestine.  It follows that injections of
        fluids that exert no remedial influence, such as air, may effect an evacua-
        tion,  and thus establish the first condition of a cure. 
ABNORMITIES  OF  THE  LIVER.
97
                         CHAPTER II.


ABNORMITIES  OF THE ACCESSORY  ORGANS OP  THE  ALIMENTARY
                              CANAL.
               SECT. I.—ABNORMITIES OF THE LIVER.

  The diseases of the liver have continued to remain to the present day
a subject of extreme difficulty, in spite of  the progress made in the ana-
tomy of this viscus.   As one of the chief organs concerned in sanguifica-
tion, it affects, as might indeed have been inferred a priori,  the somatic
and psychical character of the individual in the  most varied and exten-
sive manner within  the range of physiological bounds ; and on the other
hand, many of its morbid affections, which are beyond the reach of the
scalpel, become intelligible only by attending to the anomalies presented
in other organs.  It is to be hoped that future inquiries may elucidate
them more fully by showing the influence these anomalies have upon the
constitution of the  blood,  and by explaining the various spontaneous de-
rangements of the vital fluid.

   § 1. Arrest and  Excess of Bevelopment.—The liver is absent in very
imperfect monstrosities, especially in  acephalous monsters, in which the
heart, the lungs,  and the greater part of the intestinal canal  are also de-
ficient ; in biventral monsters  the  liver presents  more or less  marked
traces of duplication.

   § 2. On the Irregularities of Volume generally, and on Hypertrophy
and Atrophy in particular.—We  find  the liver  either  abnormally
enlarged or abnormally diminished in size.  The former defect, in which
the left lobe  remains permanently enlarged, so as to  extend to  the left
hypochondrium and beyond the spleen, is  occasionally congenital.  Both
conditions, when  acquired, become extremely interesting in a diagnostic
point of view.
   Increase in the volume  and weight of the liver depends upon—
   Firstly, Hyperaemia, congestive turgor ;
   Secondly,  Inflammation, inflammatory swelling;
   Thirdly, Congestion and stasis in the capillary gall-vessels ;
   Fourthly,  True uniform hypertrophy ;
   Fifthly, Excessive, but morbid,  nutrition, i. e.  the deposition or in-
filtration of  a  substance  foreign to the  hepatic tissue in  quantity or
quality—conditions which have hitherto been considered as hypertrophy
of one of the component parts of the organ ;
   Sixthly, Adventitious products, which directly increase the weight and
volume of  the liver in proportion to their  own number and size,  and in-
directly contribute  to that effect by the congestion they give  rise to in
the surrounding tissue.
  VOL. II.                         7 
98
ABNORMITIES OF
  Diminution in the volume of the liver  is the result  of atrophy and
alteration in the tissue.
  a. Hypertrophy.—Under this head we consider not only the abnormal
condition dependent upon exalted nutrition and increased deposition of
the peculiar normal constituents of the organ, but those  anomalies also
in which the increase of size is the  result of  excessive deposition of
separate elements of those constituents, and of the deposition of  hetero-
geneous matter.  The former is genuine hypertrophy; the latter, which
are often mistermed hypertrophy,  includes  the  nutmeg  liver, the  fatty
liver, and its variety the waxy liver;  and lastly, the infiltration of an
albuminous, lardaceous, and gelatinous substance.
  Although the last-named abnormal  conditions are closely connected
with deep-seated constitutional  and acquired derangement in  the vegeta-
tive sphere, it is of practical utility to consider them in this section until
we shall have arrived at an  accurate knowledge  of  the infiltrated abnor-
mal matter, and of the corresponding anomalies in the vegetative system
at large.   We are the more justified in  adopting this  course  as the
enlargement of the viscus, and  especially the  peculiar features  in its
growth which are perceptible to external examination, afford a valuable
aid in the recognition of these internal conditions.
  a. Pure hypertrophy, i. e. a simple increase  of the  normal  specific
tissue, can scarcely occur without  uniform  hypertrophy of all the  con-
stituents of the liver.  It is  not unfrequent; it is a result of hyperaemia,
and presents the following  anatomical signs: the liver is increased in
volume, but retains its  usual shape;  it  is  hard, lacerable  and  full of
blood;  the acini  appear enlarged,  and  of the normal reddish-brown
color.   This coarse-grained  texture must be carefully distinguished from
so-called granular liver.
  /?. The nutmeg liver.—That condition of the liver in which a separation
of the yellow and reddish-brown substances takes place, especially if the
former predominates, and which presents a close  resemblance to the sec-
tion of a nutmeg, has been termed the  nutmeg-liver; it is commonly con-
sidered as a hypertrophy  of the  so-called white  or secreting  portion,
the red portion either remaining unaltered or being more or less condensed
by the former.
  According  to our own researches the  nutmeg liver occurs under two
different conditions, and there  are consequently two varieties.
   aa. In one case it appears as an enlargement of the capillaries of the
biliary canaliculi,  accompanied probably  by hypertrophy of the latter
(the secreting substance), and  resulting from  excessive secretion of bile
and stasis of the secretion.   The two substances are the more  defined,
the darker the color of the bile and of the red substance.
   ftS.  In the other case it is due to an increased deposit of the fat nor-
mally due to the liver.
   In either case we trace several degrees:
   Firstly, In the  lowest degree the normal distinction between the two
substances is simply more  marked,  the white substance appearing more
developed;
   Secondly, In the second degree the predominance of the white sub- 
THE  LIVER.
99
stance becomes more apparent, and forms circumvolutions that envelope
the red substance;
   Thirdly, In  the  highest  degree the organ approaches, in the first
variety, to the granular; in the second, to the fatty liver.
   The liver appears, in  the second variety, to  be slightly enlarged, at
least it is never  diminished in size; in the advanced stages  it has a ten-
dency  to become flattened, and to expand whilst its edges are thickened.
   Mechanical hyperaemia of the portal system from disease  of the heart
is  peculiarly liable to encourage  the  development of the nutmeg liver.
The affection occurs very frequently; it may present no symptoms what-
ever, or be accompanied by distinct signs of hepatic disease, though not
such as to indicate  the  specific  derangement.   In the form in which it
presents  the early stage of the fatty liver, it most probably gives rise to
the numerous complaints which  are relieved by neutral salts, alkalies,
mineral waters  containing these substances, saponaceous compounds, and
the so-called resolvent vegetable  extracts.
   y. Fatty liver, the adipose metamorphosis, morbid accumulation of fat
in the  liver.—A well-marked  case is distinguished by the folloAving ana-
tomical characters : the liver is enlarged, the increase of size taking place
chiefly in a lateral direction; its edges are flattened and  swollen,  the
peritoneal covering is smooth, shining, transparent and tense; the organ
is  soft and pits on pressure ; its color, internally and externally,  is uni-
formly yellowish-red or light yellow, resembling that of autumnal foliage;
it  is pale and exsanguine, and contains a large amount of fat, as evidenced
by the greasy deposit when cut with a dry warm blade, or  as proved  by
submitting the  liver to high temperatures.
   The disease  consists in a deposition of free adipose tissue to such  an
extent as not only to replace the true glandular structure, but to penetrate
the entire parenchyma to the  exclusion of the vascular tissue.
   In the earlier  stages of the affection the various signs alluded to are
less marked.
   Two conditions chiefly favor its production:
   In the first instance it very commonly accompanies tubercular phthisis ;
and, according  to the researches of Louis, is found in two-thirds of  all
cases of  phthisis.   Andral has explained this occurrence on the ground
of impeded secretion of hydrogen by the lungs; but extended investigation
allows  us to  conclude that  this  impediment, which is not even demon-
strable, is not the cause of the deposit; but that it is an essential  consti-
tuent or pathognomonic combination of the tubercular dyscrasia, inasmuch
as it allies itself with tubercular  affections of every kind, with tubercle
of the intestinal mucous membrane, of the bronchial glands, the serous
membrane, the  bones, &c.
   Secondly; The  fatty  liver   is  also  developed—independently  of
tubercle—in consequence of a luxurious and indolent regimen, in children
that have been gorged with food, and especially as  a result of dram-
drinking.  In this case it is accompanied by accumulations of fat in the
omentum, the mesenteries, the pericardium, the heart, and the subcuta-
neous cellular tissue, by fatty degeneration of the muscular fibres of the
gall-bladder,  and even of the muscular tissue of the heart;  the common
integument has a leaden hue, and the perspiration has a greasy appear- 
100
ABNORMITIES OF
ance and a peculiar odor.  The fat bears throughout a resemblance to
tallow.
  The waxy liver is a variety of the fatty liver; it is distinguished from
the latter by a color resembling that of beesAvax, by its greater consist-
ence, dryness, and brittleness; and these qualities depend upon a peculiar
modification of the infiltrated fat, which, although accumulated to  a con-
siderable amount, leaves but feAV traces on the scalpel.
  Occasionally the  tallow is  seen deposited at  a few points  only, or it
accumulates at particular spots.  They are commonly superficial, though
they are also seen in the deeper parts in the shape of irregularly-circum-
scribed maculae, which are the more conspicuous  by their change of color
the less the other portions of the liver  are involved in the disease, and
the darker they are.
  d. Lardaceous  (speckig, baconny) liver.—Next  in order to the fatty
liver are the infiltrations of the hepatic parenchyma by a coarser, gray,
sometimes transparent, albuminous, lardaceous, or lardaceo-gelatinous,
substance.  This affection is found concurrent with constitutional disease
of the vegetative system, especially with scrofulous and rickety disease,
with syphilitic and mercurial cachexia, and  it may consequently be con-
genital.   It appears that it is occasionally developed as a sequela of in-
termittent fever in cachectic subjects.
  The following are its anatomical characters :  considerable  increase of
size  and weight, with remarkable lateral development and flattening of
the organ ; smoothness and tenseness of the peritoneal investment, a cer-
tain degree of doughy consistency combined with hardness and elasticity,
anaemia, pale, watery, portal blood;  gray, grayish-white, or grayish-red
color, tinged with yellow or brown; the surface of a section being smooth,
and homogeneous, resembling bacon, and leaving but a slight fatty stain
on the scalpel.  Sometimes, however, there is an  adipose deposit in  the
entire liver, or in certain parts of the organ, and the blade of the scalpel
then shoAvs the fatty appearance when a section is made.
  In many cases the foreign substance is also deposited in the shape of
white lardaceous spots, the  edges of which are not  distinctly circum-
scribed.
  The  spleen is very commonly affected in a corresponding manner; it
is found much enlarged, and infiltrated by a similar substance (vide Spleen).
Bright's disease of  the kidneys and analogous renal affections are also
very often complicated with the lardaceous and fatty liver.
  b. Atrophy.—Atrophy of the liver,  independent  of the marasmus
senilis of the organ, appears in various forms.   We first draw attention
to tAVO distinct forms which have not been remarked hitherto, and which,
similarly  to the hypertrophic affections, are the  expressions of a consti-
tutional malady, and have their  immediate  origin in anomalies  of  the
blood.  Owing to their distinctive coloring, they may be appropriately
termed yellow and  red atrophy.
  a. Yellow atrophy.—This affection  is characterized by the saturated
yellow color, owing  to a diffusion of bile throughout the tissue, by extreme
flabbiness and pulpiness, loss of the  granular texture, extreme rapidity
in the reduction of  size, which chiefly affects the vertical  diameter, and
consequently induces a flattening of the liver.  It  occurs chiefly in the 
THE  LIVER.
101
early years of life, during puberty, and  in the prime ;  it is remarkable
for the rapid course it runs, for extreme tenderness of the liver, nervous
attacks, and jaundice ; it terminates fatally with febrile symptoms of a
disorganized state of the blood, irritation of the brain and its membranes,
and hydrocephalic softening of the former, and with symptoms of exuda-
tion and suppuration generally, and especially of the mucous membrane,
pneumonia, &c.
   The  blood  contained in the large vessels  of  the liver, and even that
contained in the trunk of the vena portae, is reduced in  consistence, and
of a dirty reddish-brown  color ;  and the coats  of the latter vessel are
tinged with bile.   This points to the fact that the portal blood itself con-
tains such an excess of biliary constituents, that they are separated here,
and still more in the capillaries, and  thus fill  the entire  vascular and
biliary  system; the coats of the vessels and their cellular strata thus
absorb  bile  by exosmosis, the true glandular tissue fuses, is lost  in the
biliary  colliquation, and disappears.   The immediate consequences of this
condition are that the blood in the vena cava is infected  and overcharged
with bile,  causing intense jaundice;  when  this has reached a certain
point, the above symptoms terminate in a rapid consumption of the blood
and in  exhaustion.   We commonly find biliary matter of a deep yellow
color, or if the disorganized blood has exuded through the mucous mem-
brane,  a black tarry  substance in the intestine.
   (3. Red atrophy.—This is  distinguished from  the former by its dark-
brown or bluish-red color; the liver is gorged with blood, and presents a
spongy elastic consistency;  there  is  an absence of  granulation,  and a
section offers an appearance of perfectly homogeneous texture ; the organ
is reduced in size, though its thickness preponderates over the other
dimensions.
   The  disease is chronic, and is always accompanied by torpor  of the
abdominal ganglia, venous plethora of the abdominal viscera, and by the
formation of brownish-black,  or greenish-black, tarry bile,  and faeces of
a  similar constitution.  By itself it  rarely proves fatal, though death
may ensue from the marasmus brought  on by the enduring congestion of
the portal system.  In addition to these tAvo forms, we consider—
   y. Laennec's cirrhosis in its advanced stage, a chronic affection which
resembles acute yellow atrophy, but besides being chronic, is distinguished
from the latter by the liver being firm, or, if flabby, very tough.
   Granular liver  is  a variety of this species; it appears essentially as
secondary textural degeneration, and although  commonly treated of as
atrophy, and  from ignorance of the above described forms as the only
variety of atrophy, we refer  for a  minute examination  to  a subsequent
portion of this work.   Finally, we have—
   8. Atrophy of the liver from obliteration of  the ramifications of the
vena porta (vide, the  acquired Lobular  Form of the Liver, p. 103).

   §  3.   Abnormities of Form.1—These abnormities are either congenital,
and  are then in part foetal conditions of the liver, in part acquired.  To
the former belong the round, the unlobulated,  or but slightly lobulated
(embryonic) liver, the semiglobular, the  broad, the flattened, the trian-
gular and quadrangular, and multilobular liver.
                          1 Oestr. Jahrb. xx. 4. 
102                     ABNORMITIES  OF

   The acquired irregularity of form is either the result of external influ-
ences, or it depends upon an affection of the tissue of the liver.   The
former consists in a flattening of the  liver anteriorly, in indentations  or
furrows, produced by contractions or  deformities of the thorax, by stays,
exudations, enlarged viscera, or morbid growths.  The latter are of pecu-
liar interest, as the nature of the hepatic malformation, taken in connec-
tion with the increase or diminution of size, is characteristic of the inter-
nal affection of the viscus.  We shall  devote some further consideration
to this class.
   Malformations of the liver must be considered in reference :
   Firstly,  To  the relation of the vertical to the longitudinal and  trans-
Averse diameters, or the circumference of the edges ;
   Secondly, To  the condition of the edges, which may be  bevelled off,
thinned, acuminated, or thickened, enlarged, and rounded;
   Thirdly, To the state of the  surface, which may  be variously smooth
and level, or as variously  uneven.
   With reference to the  first variety, Ave are able to affirm that the de-
velopment of the vascular  tissue generally, is connected with swelling and
enlargement of the liver and with a preponderance of the vertical diameter
(thickness); that the so-called development of the yellow tissue (infiltra-
tion) is complicated  with  lateral enlargement, or increase  of size with
flattening,  and corresponding diminution of the vertical diameter.
   In  reference to the  edges, Ave  have to remark that in the last-named
states, at least in their advanced degrees, they are absolutely thickened
and rounded.
   We find the folloAving irregularities of form to occur more particularly
in connection Avith the  above-mentioned varieties of enlargement.
   1st. When the increase of size is the result of congestion,  or of tempo-
rary hyperaemic turgor, the liver retains the general outline of its normal
condition:  but if this affection becomes permanent, the vertical diameter
soon predominates considerably.  This is still more the case in genuine
hypertrophy.
   2d. The nutmeg liver, the fatty and waxy and lardaceous liver, induce
a lateral enlargement of the organ : the vertical diameter diminishes, and
the liver is flattened : this becomes more apparent when, as in the higher
degrees, there is at  the same  time, an increase  in the  substance of the
edges, i. e. when  the latter become thicker and globose.
   An evident  exception occurs Avhen  this condition takes place in  early
life, or when it is congenital.  The above-mentioned irregularity of form
is in that case less marked, as the preponderance of the vertical diameter
of the liver is normal  in the foetal state  and  during the first years  of
life.
   Even in the varieties of atrophy of the liver, the remarks made  as  to
the alterations of form, are confirmed in the main ; in the yellow variety
the liver is generally reduced in its A^ertical diameter, whereas in the red
variety, the decrease is chiefly perceptible at the edges, and the vertical
diameter consequently predominates; in the former  case the  organ pre-
sents  a disk-like shape, in the latter that of a  hemisphere or ball.
   The irregularity of  form consequent upon that textural disease which
is called the granular liver, is  very  remarkable.   It is almost  always 
THE  LIVER.
103
accompanied by a considerable diminution of size; the granulations and
the atrophy generally commence at the edges, and the  latter attains its
extreme development at this point; the edges consequently appear very
much thinned, and at last form a mere seam, consisting of cellulo-fibrous
tissue, which is contained betAveen two condensed laminae of peritoneum,
and reflected over the  convexity, or inverted into  the  concavity of the
liver.   The left lobe of the liver is frequently shrunk into a very small,
flattened, cellulo-fibrous appendix, and the thick hemispherical or globu-
lar mass of the right lobe represents the entire organ.
   Occasional exceptions arise from the granular disease being developed
in a liver that was previously affected by some  other disease, as by the
fatty degeneration;  in this case the reduction  in size  only takes place
very slowly, and  the edges  instead of being thinned  down, are  often
thickened and rounded.
   The more violent inflammations of the hepatic peritoneal lamina, affect
the surface-layer of the liver, and thus induce changes in form, that vary
in proportion to the intensity of the inflammation.  Thus the liver is not
unfrequently converted into a thick cake with rounded edges, if the in-
flammation has been uniform, or it may be converted into a globular mass,
compressed into a small space by peritoneal investment, which, in conse-
quence of  repeated  attacks of inflammation, is  transformed into a fibro-
cartilaginous tissue.   A malformation which we shall have  occasion to
revert to  subsequently (superficial lobulation)  results from  an intense
development of this process in detached spots.
   The surface of the liver offers several points for  consideration.
   Hyperaemic turgor, and still more all the  varieties of hepatic infiltra-
tion, are distinguished by their producing a smooth surface.
   Unevenness of  the surface is produced in  various forms and degrees ;
the chief forms are the racemose and the lobulated.
   The racemose form appertains to the granular liver ;  it depends upon
the granulation of the peripheral layer, and appears delicately or coarsely
moulded, of partial or uniform occurrence, in proportion to the develop-
ment of the acini.
   The lobulated  liver is  either a congenital abnormity or an acquired
malformation.
   The congenital form of this affection is owing to  an arrest of develop-
ment ;  the  liver is divided into several lobes, and this division may pro-
ceed so far as to  present  several  small livers which  are only connected
with the main organ by peritoneal folds and the  vessels enclosed in them.
This condition is  not accompanied by any perceptible shrivelling or con-
densation of the peritoneum in  the fissures or sulci, and  still less  by a
condensation of the parenchymatous cellular tissue, or an  obliterated
state of the vessels.   We may assume a priori,  and experience confirms
the view, that the lobulation commences and is chiefly, if not exclusively,
developed  on  the concave surface of the liver, as the natural point of
departure for the fissures.
   Acquired lobulation of the liver presents itself in various degrees, and
depends upon various causes.  We base our division upon the latter, and
thus arrive at their chief varieties, which at the  same time, represent as
many degrees. 
104
ABNORMITIES  OF
  Very superficial lobulation, one of which there is a mere indication, is
occasionally the result of superficial inflammations affecting the hepatic
sheath.   These induce fibrous condensation of the parenchymatous cellu-
lar  tissue, and cicatriform contraction of the im'esting peritoneum, be-
yond which the neighboring parenchyma projects in the shape of shallow,
convex, and smooth protuberances, circumscribed by slight furrows.
  A second form, in which the lobulation is  more marked, is developed
in the granular liver.  In the  same  manner as  the granulations may
produce a racemose appearance of the hepatic surface, they may, when
several  of them are  grouped together, produce  larger protuberances,
or lobes;  if the interstitial cellular tissue  is much condensed, the peri-
pheral groups may become pediculated,  so as  to resemble mere appen-
dices.
  The third form and highest degree, which  bears most resemblance
to congenital  lobulation, results from the  obliteration of one or more
branches of the  Aena portae, from inflammation and the consequent shri-
velling and atrophy of the  hepatic  sections supplied  by their ramifica-
tions.  These sections shrink in the direction of the obliterated trunk,
the peritoneum generally follows, the surface is affected, and fissures re-
sult, which run in various  directions, and above which  the healthy tissue
projects  in  the shape of large rounded protuberances.   The enlarge-
ment of these protuberances appears to be  encouraged  by the additional
labor thrown upon them, and still more so if these portions have become
the seat of fatty and other infiltrations.
  Irregularities of the hepatic surface of a different kind are induced by
the development of adventitious products, such as cancer in the liver;
but these will be discussed hereafter.

  § 4. Abnormities of Position. — Abnormities of position  are  either
congenital or acquired.  To the former belong the abnormal position of
the liver, external and internal to the abdominal cavity;  as in cases of
fissure of the abdominal parietes and eventration, of deficient diaphragm,
of  congenital umbilical hernia, of lateral  transposition of the viscera.
In  the  latter case, the entire relations of the organs  have undergone a
corresponding change, the large right lobe now being on the  left side,
and vice versa, and the vesical  fossa to the left of the umbilical fissure.
   Some of the  acquired malpositions of the liver resemble  the former,
as in the case of extensive wounds of the abdominal parietes, and of the
diaphragm, and of certain rare anomalies, resulting from acquired um-
bilical hernia.   A more common occurrence is the abnormal position of
the liver within the abdominal  cavity, in consequence either  of pressure
exerted by other viscera, or of a change in the size and weight of the
organ.   We find the  liver and the  neighboring  organs  pushed out of
their proper place by distortions of the spine ;  by hypertrophied neigh-
boring A'iscera, e. g., the right kidney, by expansions of  adjoining cavities,
as of the pericardium, but more especially of the  right pleura.  In the
latter case it is forced down  into the mesogastric region by the dia-
phragm which is depressed by the accumulation of gases or fluids in the
pleura; and as  the pressure especially affects the  right lobe, this portion
occupies the lowest position, and comes to be placed under the left lobe. 
THE  LIVER.
105
The liver may be pushed upwards  into the concavity of the diaphragm
and into the thorax, by gaseous accumulations  in the abdominal cavity,
by  ascites, by peritoneal effusion, and  by tympanitic distension of the
intestines.   It  is  as variously affected by partial exudations and by
morbid growths, and the change of position corresponds to their seat
and magnitude.
  The spontaneous change of position which the liver undergoes in con-
sequence of increase in size and weight, is invariably a descent  to  a
lower region of  the abdomen, and it follows from  the  anatomical rela-
tions of the parts  that  it must be the right  lobe which is peculiarly
involved.

  § 5. Changes of Consistency.—As these changes are always allied to
other anomalies of more importance, and have therefore been already
alluded to, or will be subsequently considered, we here only advert to
the diminution in the consistency of the organ which takes place without
any change in the hepatic tissue, in all  dyscrasic processes accompanied
by  decomposition  or subsequent to excessive elimination of the fibrine
of the blood, as occurring in typhus and typhoid states, in purulent in-
fection of the blood, and acute tuberculoses, or subsequent to extensive
exudation on serous membranes, and especially in puerperal fever.  The
liver  appears flabby, collapsed, and pultaceous ; its parenchyma is soft-
ened and infiltrated with serum, generally very pale and exsanguine, or
containing only pale, thin, and watery blood.

  § 6. Biseases of the Tissues,  a. Hyperaemia, apoplexy,  anaemia of
the liver.—Hyperaemia of the liver appears in three forms : as active
hyperaemia, resulting from idiopathic or consensual irritation; as passive
hyperaemia, dependent upon  torpor in the portal vascular system ; and
lastly, as mechanical hyperaemia,  chiefly  induced  by obstacles  in the
circulation through the heart and lungs; the last form  is one of very
frequent occurrence, and is marked by  the  intensity and extent to
which it affects the entire viscera.  In rare cases an  anomalous anasto-
mosis of the epigastric cutaneous veins Avith the umbilical veins which
have remained  permanently  open, gives rise to persistent hyperaemia of
the liver.  (Vide Veins.)
  The anatomical signs are congestive  turgor  of the viscus, increase of
size, especially in  the vertical diameter, but without any further change
of form, dark-red color, and obliteration of the yellow substance, soften-
ing of the parenchyma, and  a large supply of blood.   In habitual, and
particularly in permanent mechanical hyperaemia, the vessels in the liver,
as well as the trunk of  the vena portae, and the branches from which it
arises, are found dilated and  varicose.
  Habitual hyperaemia of the liver is apt to be folloAved by hypertrophy;
and as a consequence of an increased production of portal blood, and an
exaggeration of its peculiar qualities, the nutmeg-liver may result, which
again, may give rise  to granular degeneration of the organ.
  Apoplexy of the  liver is a very  rare occurrence; it results from con-
gestion Avhich has rapidly attained  a very high degree, and  undoubtedly
commences as capillary hemorrhage ; an apoplectic spot is  thus caused, 
106
ABNORMITIES  OF
which may enlarge and induce a rupture of larger vessels.   According
to the seat of the hemorrhage we find two varieties, viz., peripheral or
deep-seated hemorrhage ; both may however occur simultaneously.   In
the former, the hepatic peritoneum, especially that investing the convex
surface of the right lobe, is detached in  a varying extent, and under-
neath it is found fluid or  coagulated blood to a larger or smaller amount.
These hemorrhages occur chiefly in infants, as a consequence of impeded
respiration and pulmonary  circulation, from suffocative  catarrh.  The
hepatic peritoneum may become ruptured, and thus cause an effusion of
blood into  the abdominal cavity.   The liver is in a state of permanent
congestive  tumefaction, and  being overcharged with  blood, presents  a
dark-red color, and looseness of texture.   We are  reminded by these
effusions of the analogous bleedings at the cranium, accompanied  by a
detachment of either  the pericranium or the dura mater, which consti-
tute the so-called thrombus or cephalhaematoma.
  In  the second variety, apoplectic spots of various forms and sizes are
found in the parenchyma ; there are generally several of them dispersed
through the organ.  This variety is  found more  frequently in adults
than  the former, but the  two  may take place at the same time.   If  a
cure follows, a cellulo-fibrous callous cicatrix remains.
  Anaemia of  the  liver is the result of hemorrhages, exhaustion, or a
reduction of the mass of  blood by extensive exudative processes, and is
accompanied by a diminution of the consistency of the liver.   It is also
constantly associated with many hepatic diseases, such as the fatty, the
lardaceous, and waxy liver, to which we have already adverted.
  b. Inflammation of the Liver (Hepatitis).—Although inflammation of
the liver may  not be a very rare affection,  it is certain that the intense
degrees, which terminate in suppuration and abscess, do not occur very
frequently with us.  We may remark that the  most various diseases of
the hepatic tissues are at the bedside taken for hepatitis.
  If  we  sum  up the  observations of solitary instances of well-marked
hepatitis, taken in  connection with the condition of the hepatic  tissue
surrounding wounds and recent abscesses  of the liver, we find the fol-
lowing to be the anatomical signs of hepatitis previous to its termination
in suppuration:
  Inflammation never attacks  the entire  organ, but occurs  in one or
more  patches.   Commonly there is but one spot, but it may vary in ex-
tent,  and the  process is here found developed in various  degrees.  The
viscus is swollen in proportion to  the number and  size of  the inflamma-
tory patches,  and this tumefaction is particularly perceptible when  a
section is made, the turgid tissue rising above the edges of the incision
and the peritoneal sheath.   The parenchyma is loosened  and lacerable,
and the structure becomes more apparent from the enlargement of the
acini, Avhich gives the broken surface  a granular appearance ; the acini
become altered in shape, and assume an oval form; their circumference
becomes transparent, so that each acinus seems imbedded in a gray or
grayish-red  layer  of gelatinous matter, with which it is  however inti-
mately blended.  In the advanced  stage of inflammation, the granulated
structure disappears, the  tissue seems  perfectly uniform, and the broken
surface has a laminated appearance.  The  organ has a paler color, and 
THE  LIVER.
107
it is almost uniformly brown, or grayish-red in some parts, or yellowish-
red or pale-yellow in others.  The capillary vessels are filled Avith albu-
minous and fibrinous coagula.
   If the process extend to the circumference, the peritoneal investment
becomes opaque, thickened, and  is easily detached ; in many cases it is
inflamed, and covered by an exudation of varying thickness.
   Acute inflammation frequently leads to suppuration of the parenchyma
and to hepatic phthisis.   We then find small spots of pus occurring here
and there in the  infiltrated tissue, Avhich  gradually increase, coalesce,
and form an  hepatic abscess.   The  large  abscesses found  in the dead
subject may almost always be proved  to have resulted from a union  of
several smaller  spots, by the remains of the fistulous passages that con-
nected  them, by the  sinuous  shape of their circumference, or by the
de'bris of the former partitions.
   The size of hepatic abscesses varies.  They are often of the size of a
fist, or a child's head, and may even occupy an entire lobe.
   The seat of the abscess corresponds with the seat of the  preArious in-
flammation ;  it therefore most commonly occupies the right lobe, is  gene-
rally found in the deeper parenchyma, and  is often accompanied by an
abscess in the left lobe, or extends into the  latter.
   The recent abscess represents an irregular cavity with uneven parietes,
which are infiltrated with pus  and consequently very friable; prolonga-
tions of the same tissue project into the cavity.
   The abscess increases  by fusion of  the adjoining tissue, and thus  as-
sumes a round form, which becomes sinuous if a communication is esta-
blished AA'ith  other abscesses.
   When the suppurative process has reached the boundary of the original
inflammation, it meets, if no further inflammatory reaction is established
in the vicinity,  with infiltrated, tumid, and  discolored parenchyma.  In
this manner the abscess may remain passive for a considerable  period,
retaining the shape  and  other characters above described.   It is  com-
monly lined by a suppurating and loosely-attached membrane.   In refe-
rence to its contents, the hepatic abscess presents considerable differences
at different periods, depending in part upon the communication established
with the biliary vessels.   The pus contained in the recent abscess is mixed
with little or no bile, as the acini  and the capillary gall-ducts have be-
come obliterated by the inflammation; the bile contained in them at the
commencement of the inflammatory attack,  is at most found  in combina-
tion with the pus.   A large abscess of long  standing, invariably contains
pus mixed with a considerable amount  of bile, which arises from the com-
munication established betAveen the cavity and larger gall-ducts.  These
are, like the bronchi, affected by a continuation of the suppurativeprocess,
and are generally eaten across in a transverse or slanting direction; and
in exceptional cases only, and in very  large abscesses, are they attacked
and opened laterally.  The pus contained in old abscesses is always dis-
colored, generally greenish, and possessing  a strong  ammoniacal odor:
we must undoubtedly attribute to it  the extensive discoloration of the
surrounding parenchyma.  The bloodvessels opening into  the abscess are
blocked up, so that hemorrhage very rarely occurs.
   Before a fatal issue takes place, the hepatic abscess may discharge its 
108
ABNORMITIES OF
contents in different directions, and  with  various results.   The dis-
charge is very rarely effected into the peritoneal sac, as from the perito-
neal investment having  been either primarily or secondarily involved in
the inflammatory process, adhesions will have  been formed, which pre-
vent this occurrence.  We have to notice the folloAving modes of dis-
charge :
   a. The hepatic abscess induces suppuration in and between the thoracic
and abdominal parietes, and after a communication has been established
betAveen the former and the superficial abscess, it discharges externally
by straight or sinuous,  narrow or wide passages;  and by this  means  a
cure is sometimes brought about.
  13. The diaphragm may be perforated, and a discharge be effected into
the right pleura, where, sooner or later, fatal inflammation is set up;  or
if the lung had previously been agglutinated to the diaphragm,  suppura-
tion of the  pulmonary lamina of the pleura follows, and an opening being
effected into the bronchi, pneumonia and pulmonary abscess supervene.
   y. The hepatic pus may be eliminated  by  the bronchi.
   d. The contents of the abscess may be discharged  into the  stomach,
the duodenum, and the  colon; and in these  cases the hepatic abscess  is
reported to have healed.
   e. A discharge may take place into the gall-bladder, or more frequently
into one of the larger branches  of the hepatic duct, the hepatic pus  is
conveyed to the intestine by a longer passage, and thus escapes.
   Z. Cases in which the central aponeurosis of the diaphragm  is perfo-
rated, and the pus discharged  by longer  or shorter sinuses into  the peri-
cardium, inducing pericarditis, are very rare.  They have been  observed
by Smith and Graves, and  once by ourselves.
   fj. Finally, very rare  cases haATe occurred  in which the hepatic abscess
has discharged itself into large vessels, such as the vena cava;  we have
observed a case in which a communication  was established  between an
hepatic abscess and the  vena portae and duodenum.
   A cure of the hepatic abscess is effected  after the  pus has been dis-
charged by one of the above-described methods, or it may result without
this occurrence from more or less complete absorption of the pus by the
cellulo-vascular membrane investing the sides of the abscess; for, as soon
as that  portion of the parenchyma Avhich  has undergone purulent infiltra-
tion is entirely broken down, the abscess comes in  contact with  a surface
of tissue which is in a less inflamed state, or which does not put on any
reaction till now.  This, however, gives  rise to an exudation, which in-
vests the smoothed surfaces of the abscess,  and after being repeatedly
redissolved, at last forms a permanent  coating.  The  subjacent layer in
the interim has been converted into fibro-cellular tissue, and the cellulo-
vascular investment becoming incorporated  with the former, induces  a
gradual absorption of the enclosed pus, the walls of the abscess gradually
approach one another, and  at  last unite to form a  callous cicatrix.  Not
unfrequently a remnant of pus, which is  converted into a cheesy concre-
tion, and gradually becomes cretified, may still be found locked up in the
tissue of the cicatrix; the parenchyma, lying above the situation of the
original abscess, is found collapsed;  and if the abscess extended to  the 
THE  LIVER.
109
circumference, the hepatic  peritoneal lamina forms  a cicatrized, dense,
shrivelled covering.
   The true glandular tissue of the acini, and  the interlobular tissue, are
undoubtedly to  be considered  as  the seat of the inflammation we have
just examined;  it must be  carefully distinguished  from inflammation of
the capillary gall-ducts, as well as from abscess resulting from suppura-
tion in the latter, which is characterized by its large admixture  of bile.
We  shall advert  to  this form in connection with diseases  of the gall-
ducts.
   In the same manner we have to  distinguish between the hepatic abscess
above described, and secondary or metastatic purulent deposits.
   Induration and obliteration  of  the hepatic parenchyma are the more
frequent result of slight and chronic inflammatory attacks.  The  product
of inflammation solidifies, and the hepatic parenchyma becoming oblite-
rated, is converted into a cellulo-fibrous  callosity, which gradually con-
tracts, and  induces a collapse at  the surface of the liver proportionate
to its vicinity to the surface.   If  this  occurs  simultaneously at several
points,  the  surface  of  the organ obtains an  uneven, undulated,  and
slightly  lobulated appearance.   These accumulations of  cartilaginous
tissue are to be distinguished  from the obliterations and atrophy which
affect the hepatic tissue, as  a result of obliteration of the portal ramifica-
tions consequent upon phlebitis.
   The investigation of true chronic inflammation of  the  liver offers still
greater difficulty, inasmuch as, in the dead subject, we generally have to
deal with its products only, in various degrees  of development; many
cases of the so-called granular liver are probably referable to this head.
At the bedside, the most heterogeneous conditions when accompanied by
tedious and oppressive morbid  sensations and by painful symptoms, espe-
cially by enlargement, are diagnosed as chronic inflammation of the liver.
   c.  Inflammation of the vena portae.—This is, under all circumstances,
a very important affection.   It occurs both in a primary and in  a secon-
dary form,  and may in  either  lead  to obliteration or suppuration, and
may attack the trunk and  the ramifications of  the vessel, or the latter
only.
   Inflammation ending in obliteration of the branches of the vena portae
within the liver demands a  special notice, as it  occurs very frequently,
although we rarely have opportunities of investigating it in the dead sub-
ject otherwise than in its termination and its consequences.  It Avould
appear to be owing to an anomalous  condition of the  portal blood, and
to belong to the adhesive form.   Several  cases that we have  observed,
in which irregular anastomoses were  discovered between the portal and
the  general venous system,  by means of the patulous umbilical vein, seem
to authorize this view.
   Under certain indented  and contracted parts of the surface of the
liver, Ave discover an accumulation of cellulo-fibrous callous tissue, which,
on more minute examination, is found to  conduct to a larger or  smaller
portal branch, with which it is connected.  The vessel itself is converted
into a ligamentous cord, or it is plugged up with a fibrinous, cheesy,  or
calcareous deposit.
   The consequences of the obliteration are,  atrophy of that part of the 
110
ABNORMITIES OF
liver which is supplied by the ramifications of the vessel, lobulation of the
liver, as described at page 103, and in extreme cases, ascites.
  d.  Beposits, metastases in the  liver.—Metastases occur  in the liver
under the  same  conditions under Avhich they take place in the lungs.
They are, however, much less frequent in the former than in the latter
and in the  spleen ; and  the  so-called hepatic  abscess, more _ especially
consequent upon important surgical operations, wounds and injuries of
the cranium, is found much more rarely than has been hitherto supposed.
Besides, we always simultaneously discover deposits in other organs, par-
ticularly in the lungs and the spleen.  We are unacquainted with the
special conditions which give rise to a predominant deposit  in the liver,
with the exception of those cases  in Avhich the source of the poisoning of
the blood is within the compass of the portal system.
  The deposit in the liver is  also caused by the deposition or exudation
of fibrin through the coats of the capillaries into  the tissue, or by the
coagulation of the blood in the capillary  rete of vessels.   In both cases
metamorphoses may ensue Avhich  vary according  to the  nature of the
morbid essence absorbed into the blood; occasional induration and shrivel-
ling are induced, Avith consequent obliteration of the  parenchyma and
the capillaries;  more frequently purulent or ichorous fusion result, and
then either suppurative inflammation  of  the surrounding parenchyma is
established, or a solution of the coats of  the capillary vessels is effected.
  The deposit presents, as  in the lungs, the appearance of a circum-
scribed nodulated accumulation,  of  a dark-red or brownish-red color,
which, as it approaches the state of fusion, is converted into a dirty yellow
or greenish color.
  The deposit has a rounded form, varying in size from that of a pea to
that of a Avalnut;  it is found in considerable numbers, and is commonly
seated in the peripheral layer, where  it gives rise to inflammation of the
hepatic peritoneal lamina.  This is a  guide to distinguish it  from the ab-
scess  which originates in idiopathic inflammation of the liver; the diag-
nosis  is also aided by the acute course of the affection, by its origi-
nating in  another morbid affection, by the typhoid symptoms, by the
occurrence of similar processes in other organs, more especially in the
lungs and the spleen, by the disorganization of the blood,  and the re-
sulting jaundice.
  e.  Gangrene of the liver.—Gangrene of the liver is very  rare, in fact
Ferrers and  Be*rard  deny its occurrence, but we have seen  it in one
well-marked case,  associated with pulmonary gangrene.  It  is developed
in parts affected with inflammation and  suppuration, not  so much as  a
result of intense inflammation as of certain peculiar conditions, which
cause a tendency to gangrenous degeneration.  It occurs in more or less
circumscribed spots, in which the parenchyma is dissolved into a brown
or greenish-black pulp, which diffuses the characteristic odor of sphacelus.
We find suppuration in  the  vicinity, which is the product of reactive
inflammation,  and Avhich defines the boundaries of the mortified part.
  /. Granular liver.—Granular liver is one of the most important, though
in many respects, and especially in  reference to its pathogeny, one of
the most enigmatical affections of the liver; it is termed  by Laennec
cirrhosis : older authors have considered it  identical Avith or  related  to 
THE  LIVER.
Ill
scirrhus ;  and if viewed in reference to its termination only, it may be
called induration of the liver.
  It undoubtedly presents many degrees, which merge into one another ;
from the very unsatisfactory state of our knowledge, however, in refer-
ence to the elementary process and fundamental nature of the disease, we
consider it necessary to sketch the  affection as seen in a marked  case,
without any further complication, and subsequently to state what is known
of the earlier stages of the disease, and of the later metamorphoses of
the organ.
  In a case of the kind alluded to, theviscus appears considerably  dimi-
nished in size, and this  decrease is accompanied by a characteristic change
of form.   The margins are thinned doAvn to such a degree,  as  to repre-
sent a cellulo-fibrous seam, which is folded upon the remainder of the
organ;  the vertical diameter of the liver has increased, and is found to
consist chiefly of the hemispherical or globular right lobe. (Vide p. 103.)
  The external surface presents a granular, warty, racemose appearance,
which results from the projection of the peripheral so-called granulations,
of the liver.   These granulations may all have the same  size, e. g.  that
of  a hemp-seed,  and the  surface then is uniformly racemose : or they
vary in size, and the surface is then unevenly racemose.
   The hepatic surface intervening between the granulations is of a dull
white color, tendinous, shrivelled, and contracted;  the  granulations are
thus circumscribed, separated from one  another, and even occasionally
pediculated.
   The viscus, when it has this appearance, is to  a certain extent elastic
and tough, and even indurated, so as to offer a cartilaginous resiliency;
it cannot  be broken, as it possesses the tenacity of leather.
   The scalpel itself confirms the fact of induration, as  the instrument
meets  with  a scirrhoid  substance, which  may even  cause a crunching
sound.
   A section shows  the above-mentioned granulations to be either isolated
or grouped together; an accumulation of dirty  white, dense, resilient cel-
lular tissue, which  is almost destitute of bloodvessels, and which forms a
nidus for  the former, is seen between them.
   The color of the organ is variously modified ;  being dependent upon
the color, either of the granulations, which we  shall have still further  to
examine,  or of the  intervening fibro-cellular tissue.
   The liver is frequently attached to adjacent parts, especially to the
diaphragm, by means  of cords or laminae of neAV matter; the adjoining
peritoneum,  and especially the peritoneal  covering of  the  gall-bladder,
and the folds which leave the liver, are opaque, shrivelled, and tendinous.
   The granulations have given rise to the name of granular liver ; and
from the  coexisting atrophy and diminution of size, the affection is also
termed granular  atrophy of the liver.
   The granulations are the most prominent  sign in the  sketch we  have
given, and the question arises as to their nature.
  Laennec vieAved  the granulations  as an adventitious  product, and  as
his specimens offered a yellow color, he termed it cirrhosis (xtfifioq, fulvus).
   One may  easily be convinced  of the incorrectness of this  view, as a 
112
ABNORMITIES  OF
careful examination at once proves that the granulations  consist of no-
thing but hepatic parenchyma, which, however, as we shall subsequently
haATe occasion to show, is variously modified.
   It follows from our demonstration that in granular liA^er the hepatic
parenchyma has become reduced to the granulations, and  that the por-
tion which has disappeared, has been replaced by fibro-cellular tissue.
   The desire to obtain more accurate views as to the nature of the granu-
lations and their mode of origin, has caused the  promulgation  of various
doctrines which are untenable or incomprehensive in proportion as their
authors attached too much importance  to the ideas of hypertrophy and
atrophy and their combination, or attempted to construct a theory from
isolated observations, or because they did not sufficiently distinguish be-
tween the diseases of the hepatic parenchyma preceding the formation of
granulations, and those affecting the granulations themselves,  and other
morbid conditions not essentially connected with them.
   According to Bouillaud,  with whom Andral  coincides in  the main, the
granulations are the result of hypertrophic development of the so-called
Avhite or secreting  substance, accompanied  by obliteration and gradual
atrophy of the red or vascular tissue.
   Cruveilhier advocates a  different  opinion.  He thinks  that cirrhosis
consists in the atrophy of a considerable number  of the  hepatic acini,
accompanied by hypertrophy of the remainder, which, as  it were,  take
the place of the former.
   We  pass over  the  unsatisfactory and  erroneous  doctrines of other
writers, which are based upon investigations of solitary cases,  or  of ano-
malies in the elementary tissue, and merely remark, that we do not adopt
any one of the above views exclusively, as they do not appear to us to
embrace the entire characters of granular liver.
   Granular liver  presents considerable varieties.   The  granulations
themselves offer numerous variations in reference to  texture, number,
size and form.
   With regard to  their  texture, we sometimes  find  that they consist of
normal, or at least tolerably normal, hepatic parenchyma.  Commonly,
however, this is not the case ; the parenchyma of the granulations is itself
abnormal, and variously diseased; such cases render the analysis of the
hepatic granulations difficult, and cause errors  in the conclusions arrived
at, as  not sufficient attention is paid  to  the  distinction  betAveen  the
essential and non-essential characters  of the  abnormity.   The  altera-
tions of tissue in the granulations are either such as constitute the causa
proxima of the entire metamorphosis, i. e. they are essential, or  they
are mere  accidental complications, which may either precede or  accom-
pany the formation of granulations.   As we shall subsequently have to
show the  development of the granulations from the former and as we
are also compelled to examine into the complications of granular liver
we here give a summary of the  abnormal  conditions, without reference
to the  above distinctions.

   Firstly. The parenchyma of the hepatic granulations occasionally pre-
sents a coarse-grained hypertrophy  of the acini,  the granulations  pro- 
THE  LIVER.
113
jecting on a sectional surface in the shape of dark reddish-brown and
elastic points.
   Secondly. It frequently appears in the various degrees of the nutmeg
liver (Laennec's cirrhosis of a low degree).
   Thirdly.  The granulations appear in the shape of rounded or lobular
convolutions of dilated,  turgid, yellow, gall-ducts, the red vascular sub-
stance in the vicinity having  disappeared.   This yields one of the com-
monest and most exquisite forms of the granular liver; it is  genuine
cirrhosis, which originates in the  first variety of the  nutmeg-liver, de-
pendent upon stasis and dilatation of the biliary ducts.  The majority
of authors have evidently taken  their description of granular liver from
specimens of this kind.
   Fourthly. The parenchyma of the granulations is frequently infiltrated
with fatty matter or similar products, and the granulation then presents
on a small scale all the signs discussed at page 98.   Gluge has evidently
employed a specimen of this description for his investigations.
   Fifthly. We  occasionally find the granulations in  the condition  of
what we have termed yelloAv acute atrophy; they are then yellow through-
out, and appear at  the surface and on section  as pulpy,  collapsed,
friable, yelloAv  masses.
   Sixthly.  The parenchyma of the hepatic granulations frequently pre-
sents symptoms of an inflammatory condition; it then appears pale, of
a  homogeneous structure, with  obstruction  of  the  small biliary canali-
culi, commencing induration and obliteration.
   The granulations vary much  as  to number, and are either uniformly
distributed  through the  surrounding cellulo-fibrous  tissue, or they coa-
lesce into groups of various extent.   The more numerous they are, the
less the  hepatic parenchyma is destroyed;  the  number of the granula-
tions  therefore indicates the degree of atrophy  that  has  taken place,
and, if we take the quality and quantity of the textural changes  into
consideration, the stage  of the disease generally.
   The size of the granulations varies from that of a pin's head to that of
a horse-bean, according  as a single acinus, or an entire  lobule, or a large
portion of the  organ is affected ; they are generally of a rounded form,
though they are very frequently  of an irregular and especially of a lobu-
lated shape.  In the majority of instances we find one size and form to
prevail.
   The  cellulo-fibrous tissue intervening  between  the granulations, is
either diminished or increased  in amount.   There is generally an inverse
ratio between  this  tissue and the  number of granulations; but we find
exceptional  cases in which the granulations  are very numerous, and the
interstitial cellular tissue is also much increased.   The latter varies much
as to density, resiliency, vascularity, succulence, and color.  Sometimes
it  is loose, friable, vascular, more  or less reddened, and succulent;  at
other times it is tough, less succulent, of a dirty gray or greenish color,
at  others again, dense,  indurated,  dirty white, of fibro-cartilaginous,
scirrhoid, resiliency and  elasticity,  crepitating when cut, &c.
   Having discussed the  two constituent parts of granular liver, we must
noAV examine into the origin of the  metamorphosis.
   We  have seen that in granular liver the granulations represent the
    VOL. II.                         8 
114
ABNORMITIES OF
persistent hepatic  tissue, and that the parenchyma which has  been re-
moved is replaced  by cellulo-fibrous tissue.  The question arises whether
this reduction is primary or secondary, and supposing  the  latter case,
which  is the  primary anomaly ?   It  is commonly set down  as mere
atrophy, in consonance  with the vieAV of the  French  observers above
quoted.
  We are not of opinion that granular liver  always takes  its  origin in
the same fundamental affection; Ave  are  inclined to adopt  two morbid
states as the essential and original anomalies, Avhich give rise to granu-
lations in the  hepatic parenchyma as  a secondary affection.
  a. In  one case  there is a morbid  development of the capillary gall-
ducts (the so-called secreting tissue); an accumulation of the secretion,
and probably also  a hypertrophy of the parietes of those vessels giving
rise to the  nutmeg liver, and to an obliteration of  the  capillary blood-
vessels, the so-called vascular substance.   We then have to do Avith the
gradual reduction of the organ, already described under the head of
Atrophy, as an advanced stage  of cirrhosis;  in this condition  granular
liver takes  its origin, for the granulations  are formed by the  biliary
ducts coalescing into rounded fasciculi or  coils of the size of a pin's head
or hemp-seed.   They are more or less of a yellow color, containing  fat,
and either solitary or collected into lobular groups ; they are surrounded
by a spongy, cellular, soft, succulent,  red, and vascular tissue, from which
they can only be separated by rupture of the  latter  and of its vessels.
This anomaly  is commonly met  Avith in various degrees of development
at different  parts of the viscus;  it is generally more advanced  in  the
peripheral portions, the deeper portions presenting  at the  same time the
appearance of the  nutmeg degeneration ; the liver is frequently enlarged,
but certainly not diminished in size, and preserves the thick, massive
edges peculiar to the nutmeg liver.
  A secondary metamorphosis now  gradually supervenes, the stage of
obliteration and atrophy.    The  interstitial  tissue gradually  loses its
vascularity, its red color, succulence, and spongy  texture; it becomes
more and more pale, of a grayish-red, and dirty white color ; it shrivels
up, and becomes  denser and drier,  coriaceous, and  even  of  scirrhoid
hardness ; and it presents a cellulo-fibrous, fibro-cartilaginous structure.
The granulations  at the same  time  undergo important  modifications.
The obliteration of the interstitial tissue not  only destroys the vascular
connection between the latter and the granulations, but, as their nutri-
tion becomes impaired, their secreting power  also ceases.  We  now find
the granulation enclosed in a cellulo-fibrous case, from which it may be
easily removed, as it is only connected with its investment by a feAV de-
licate cellular threads, or is even quite detached, with the exception of a
single vascular pedicle;  it is found  collapsed, pulpy, of a dirty yellow
color ; it gradually diminishes in size, the surrounding tissue also becom-
ing atrophied; it soon appears only as a minute yellow or  greenish spot,
and at last vanishes entirely.  In exceptional  cases, in which  the liver
has become so much indurated as to be  incapable of further condensa-
tion, the tissue surrounding the individual granulations is converted into
a cyst with a serous lining, in which the granule floats, attached only by a
vascular footstalk, and surrounded by a yellowish or pale green, watery, 
THE  LIVER.
115
or gelatinous fluid.  In  consequence of the vascular obliteration, it  is
gradually so much  reduced as at last to present nothing but  a minute
nodule attached to the internal surface of the cyst, which is now entirely
filled with the fluid.
   In this variety, therefore, the original anomaly consists in the hepatic
parenchyma being  gradually reduced to the capillary  gall-ducts which
have assumed  the shape of the granulations ;  and in so far as this is
genuine cirrhosis of the liver,  it certainly bears some resemblance to the
pulmonary  cirrhosis described by Corrigan.  The secondary  metamor-
phosis causes a gradual  atrophy of  the granulations, accompanied by a
predominance  of the  interstitial  cellulo-fibrous tissue, and a uniform
diminution of the entire organ.
   The degree  attained  by the metamorphosis  is  proportionate  to the
number of obsolete granulations, or to  the amount of parenchyma re-
maining  capable of performing its functions ; the organ decreases in pro-
portion to the shrivelling and condensation  of  the interstitial, cellulo-
fibrous tissue;  and it often appears  reduced to one-quarter, or  even one-
sixth,  of its  ordinary size.   The  condensation of the cellulo-fibrous
tissue, as it gives rise to a decrease  of the organ, also induces a corruga-
tion and shrivelling of the peritoneal investment.  The latter will be
more or  less opaque, and  thickened; and,  being retracted betAveen the
projecting granulations, these not unfrequently appear to haAre a neck-
like contraction.   These changes in the hepatic peritoneal covering take
place without any symptoms of inflammatory action.
   The secondary metamorphosis chiefly affects the margin of  the liver,
and more particularly the  left lobe.   The organ  very commonly appears
to have been almost or entirely deprived of parenchyma, and  to consist
exclusively of fibro-cellular tissue,  the  edges more particularly being
thinned off and turned back upon the body of the organ, the left lobe of
which is converted into a mere appendix of fibro-cellular structure, of the
size of a hen's egg or a walnut.
   Not unfrequently the  granulations assume, in the advanced stages, and
after a long duration of the disease, a bluish or dark-green  color, which
particularly affects those seated at the concave surface of the liver.
   This form of cirrhosis of the liver undoubtedly originates in hyperaemic
states, a vieAV that is  confirmed by their  frequent connection with
organic  disease of the heart: its frequent occurrence in drunkards also
points to a peculiar anomaly in the  constitution of the portal blood.
   13. In  the second case, the original affection of the hepatic parenchyma
in granular liver is proved, by the post-mortem appearance of the granu-
lations, to consist in a slow chronic inflammation.  This induces a gradual
obliteration of the parts attacked, and their conversion into fibro-cellular
tissue, the amount of which varies in proportion as the processes of ab-
sorption or of organization predominate in the inflammatory  product.
This secondary metamorphosis, from not occurring uniformly, results in
a subdivision of the organ  into larger or smaller scattered compartments,
which present  the characteristic rounded form of the granulations in the
same ratio as they correspond to single hepatic lobules.  Their paren-
chyma is frequently found in the original state of chronic inflammation, 
116
ABNORMITIES OF
but it may be unchanged, or it may offer one of the other accidental ano-
malies alluded to.
   It is intelligible that the diminution of size in this variety is often in-
considerable, that  the organ may even be enlarged, and that the fibro-
cellular tissue is accumulated in such a manner as to preponderate over
the parenchymatous cellular  tissue.   A marked decrease of size occurs
when the obliteration  is extensive and the  cellulo-fibrous tissue  has
shrunk; and as this decrease advances, the pressure exerted by the shri-
velled tissue upon  the parts not originally affected by the anomaly, in-
duces an atrophy in them;  they fade, and put on a rusty or dark yellow
color.
   Granular liver frequently presents an abnormity which appears peculiar
to this variety.   We allude to the presence on the condensed peritoneal
investment of pseudo-membranous formations, of a cellular or cellulo-
fibrous texture, which generally extend to  the diaphragm  in the shape-
of corded adhesions.  They are the result of inflammatory processes,
which have become extinct long before the occurrence of the secondary
metamorphosis, and which appear to afford  evidence of the inflammatory
nature of the hepatic disease itself.
   Besides these tAvo modes of development of  granular  liver, the affec-
tion may also be viewed as a retrograde process,  manifested in  deposi-
tions or infiltrations of the hepatic parenchyma, arising from an anoma-
lous state of  the blood.
   In reference to  the external conformation of granular liver, we have
still to advert to a variety which is characterized  by the hepatic paren-
chyma not being reduced to granulations, but continuing in large masses,
the more superficial of which are pushed out by the shrinking interstitial
tissue, and being more or less contracted at their  base, cause the entire
organ to appear lobulated.
   Granular disease of the liver is found complicated with all the essential
or  accidental anomalies  which we have described as  occurring in the
paranchyma of the granulations, and these  anomalies may either precede
the granular  disease or supervene after its development.   The complica-
tions may be hypertrophy, nutmeg liver, cirrhosis, adipose and other in-
filtrations, acute yellow atrophy, inflammatory and other hepatic diseases.
The granular disease arising from one of the essential anomalies, e. g.
from  inflammatory causes,  is more particularly liable  to  combine with
another essential anomaly, as, for instance, with true cirrhosis.
   The complication with adipose deposit is peculiarly interesting.  The
latter may,—
   Firstly, be the  primary affection upon which the granular disease is
grafted in the shape of cirrhosis.   As the cirrhosis advances, the reduc-
tion of the organ  generally, but more particularly of the marginal por-
tions which have been infiltrated with fat, is impeded, and  the  atrophy
that does take place is  characterized by its affecting  the margin much
less than in the uncomplicated form.
   Secondly; the adipose deposit may supervene upon a granular  state
of the liver ;  and if it does so  before the secondary metamorphosis has
advanced very far, and whilst the granulations are still very numerous
it may prevent the liver from assuming the form peculiar to  the granular 
THE  LIVER.
117
condition.   If it  occurs at a  later period, it need not  modify the  cha-
racteristic form of the organ.
  Thirdly;  the  cirrhotic and shrinking granulation which is cut off by
dense cartilaginous interstitial tissue may degenerate into a flabby, dirty
yelloAvish-brown fat-lobule, the degeneration apparently proceeding from
the confined biliary matter.
  A similar relation exists in regard to  the modifications of  form be-
tween the granular condition and other infiltrations of the hepatic paren-
chyma.
  Granular liver is also very frequently coincident with the most various
morbid affections of the heart, which give rise to congestion in the vena
cava and in the  portal  system; of these, hypertrophy, dilatation, and
valvular disease  are the  most common.   Disease of the  heart must be
considered as an important momentum in the origin of the hepatic dis-
ease.
  The symptoms resulting from the granular state of the liver bear a
ratio with the degree of its development; the impermeability and oblitera-
tion of its secreting tissue induce, on  the  one hand, congestion in the
portal system, hyperaemic states of  the intestine and of the peritoneum,
a blennorrhoic condition of the  former, tumefaction of its membranes,
and ascites; on the  other, dyscrasic conditions of the blood  allied to
scurvy and  frequently accompanied by icterus, an inclination  to exuda-
tive processes, with an especial proclivity to hemorrhage, anasarca, and
anaemia.
  We cannot admit that the relation existing between Bright's disease
of the kidneys and granular liver, though the two often coexist, has been
accounted for.   In one set of cases both affections would seem to have
originated in common causes  ; in another, Bright's disease is  evidently
of more recent date, and has supervened upon the existing granular state
of the liver; but whether in this case it is due to a separate cause,  or  is
owing to the dyscrasia accompanying the hepatic disease, we are unable
to determine.
  Granular liver is invariably a chronic affection, which may often be
arrested in its development for a short time, but  never permanently.  It
terminates fatally by inducing anaemia and tabes complicated with dropsy;
by disorganization  of  the blood, by exhausting  and paralyzing exuda-
tions on the serous membranes, and especially on  the  peritoneum.   It
rarely occurs before the prime of life, but we have seen one case of it at
the age of seventeen.
  g. Adventitious  growths,   a. Anomalous  production of fat.—This
occurs in two distinct forms.   We have already become acquainted with
one in the shape of adipose deposition, or infiltration of the hepatic tissue
Avith free fatty matter;  the  second is very unusual, and  appears  as  a
lipomatous  morbid growth of a rounded  or lobulated form, and rarely
larger than a pea.
  /3.  Cavernous tissue.—This is remarkable from its frequent occurrence
in the liver.  It resembles the tissue  of the corpora cavernosa, and  is
commonly found in the peripheral substance of the liver only; from its
dark-blue color  it  shines through the peritoneum, and  the  affection  is
therefore recognized on the external examination of the organ.  It varies 
118
ABNORMITIES  OF
in size, from that of  a hemp-seed or pea to that of a hen's egg, and
more ;  is generally irregular in form, and its cells contain a large quan-
tity of dark blood; a connection may be always traced between the latter
and some larger portal vessel.  According to the amount of  blood con-
tained in the compartments, these are found  in the dead subject project-
ing beyond the surface of the liver, or collapsed and sunk.  Sometimes
they are single, sometimes numerous.
  y. Cysts.—The liver is more liable to the formation of encysted tumors
than any other parenchymatous organ; and  we  repeat that the rarity of
tubercular  deposit in the liver enhances  the importance of the hydatid
theory.  We find in the liver—
  aa.  The simple serous cyst, a serous sac containing a clear watery fluid ;
this is not met with as often as
  /?/S.  The acephalocyst of Laennec; which in the first instance is merely
a serous, but from acquiring a fibrous investment, is converted into a
fibro-serous sac, containing, besides serum, the  so-called acephalocysts;
these are small bladders (hydatids), formed of coagulated albumen and
filled with an albuminous fluid; they vary in size and number, and are
either attached to the parietes of the former or  float in the serum.
  The  acephalocyst generally attains a  considerable size  in the  liver.
We have several extraordinary specimens in the Viennese museum, and
there is one of  a  foot  in  diameter.   In  proportion  as the heterologous
growth increases, the hepatic parenchyma gives way, and the  nearer the
former originally was to the surface, the sooner will it reach the peritoneal
investment; it then projects  above the liver, with  a larger or smaller
segment of its circumference.   Under these circumstances the peritoneum
invariably inflames, and the consequence is  a thickening of  the latter
upon and in the vicinity of the acephalocyst; an investment of pseudo-
membranous cellular  tissue is formed,  by  which  the  viscus becomes
attached and agglutinated to adjoining organs.
  Sometimes there is but one, sometimes there are several of these cysts;
in rare cases, the entire liver  appears converted into an aggregation of
larger  or  smaller sacs.   In the latter instance, two or more are  often
found to communicate with one another; either in consequence of atrophy
of their parietes from pressure, of rupture from inflammation, or from a
sudden increase in their contents.
  The right lobe  of the liver  is the ordinary seat of the acephalocysts ;
the largest are always found at this part.
  Acephalocysts  are  liable to inflammatory attacks, which entirely re-
semble those of normal serous and fibro-serous membranes, both in regard
to the  exudations they give rise to, as to their terminations and consecu-
tive results.  They may, by causing suppuration and  obliteration,  de-
troy the vitality of the acephalocysts, and thus  bring about a  cure.
  The hepatic acephalocyst may discharge its contents in various direc-
tions ;  the  portion that projects above the surface of the organ  and has
lost the support it preAdously received from the surrounding parenchyma
may become atrophied and thinned, or its tissue be weakened or destroyed
by inflammation  and  suppuration, and thus communicate  directly with
the abdominal cavity; or  having first become agglutinated to neighboring 
THE  LIVER.
119
viscera,  it may perforate the latter and discharge externally, or into
other cavities and canals.   The contents may thus make their way
   Into the right pleura, or into a pulmonary abscess, and be removed by
the bronchi:
   Into the intestinal cavity, and  especially  into  the duodenum  and
transverse colon, so as to pass off by vomiting  or defecation:
   Into the gall-ducts, i.  e. into a large branch of the  ductus hepaticus,
by Avhich passage they may ultimately be conveyed into  the intestine;
though the  protrusion  of the  acephalocyst  more frequently induces
dangerous obstruction of the biliary passages :
   In rare cases, into a neighboring bloodvessel, and lastly :
   Into a  neighboring circumscribed abscess,  resulting from  peritoneal
inflammation.
   Occasionally  the acephalocyst opens  in  various directions at  once.
After  the discharge of  its contents, obliteration of the  sac and cure,
sometimes follow.
   The contents of the sac are discharged unaltered or changed, accord-
ing to  the process accompanying its perforation; the products of inflam-
mation in the matrix, or  of the parietes of other cavities (e. g. the pleura),
the bile, the  intestinal secretions, &c, are particularly  prone  to induce a
maceration and complete solution of the acephalocyst.
   On the other hand, not only the parietes of the investing sac are often
found  saturated with bile, but the bile extravasated from large gall-ducts
is frequently mixed Avith its contents, and its parietes are incrusted with
inspissated bile.   In the same  manner we may now and  then discover
blood in the cyst, which has been discharged from neighboring vessels.
   The hepatic parenchyma is forced out of its  position in  proportion to
the size and number of the cysts; if otherwise affected, it presents the
nutmeg degeneration.
   Acephalocysts in the liver are frequently complicated with affections
of the same kind in other organs, as the lungs, spleen,  and kidneys;  the
disease is  also  complicated Avith cancerous affections  in  other organs.
Large  acephalocysts  of  the liver give rise to ascites or peritonitis, and
may thus prove fatal.
   In reference to the etiology of these growths, it appears, according to
some observations,  that  mechanical injury of the liver  and intermittent
fevers may influence their development.  They seem not to occur before
puberty.
   d. Tuberculosis of the liver.—Contrary to  the received opinion, we
assert that the liver is rarely the seat of tubercular disease.   It scarcely
ever occurs in this organ as a primary affection, but is  not unfrequently
found  as  a secondary complication of advanced primary tuberculosis in
another organ, or  of universal tubercular disease.   It must, therefore,
almost always be considered  as the expression of  advanced tubercular
cachexia.
   Hepatic tubercle occurs  in  the shape of semi-transparent, grayish,
crude,  miliary granulations ; in which case it is more especially the pro-
duct of acute tuberculosis ; or as yellow, cheesy, adipose deposits, of the
size of a hemp-seed, or  pea, or more.   It is consequently often larger 
120
ABNORMITIES OF
than pulmonary tubercle;  but, on the other hand, with the exception of
very rare cases, is much less extensively disseminated than the latter.
  Hepatic tubercle  is not limited in its  seat to a particular section of
the viscus, but attacks all portions indiscriminately, and the more so, the
acuter its course.
  The tubercular matter  is deposited in  the  parenchymatous cellular
tissue of the organ, and especially in that pertaining to the biliary capil-
laries.  It very frequently surrounds a minute gall-duct, and  thus pre-
sents a central canal, Avhich  gives rise  to  a biliary discoloration of the
nucleus.
  When the liver is attacked  by acute  tuberculosis,  its appearance
resembles the parenchyma of other organs similarly affected;  it is in a
peculiar  state of turgescence, the tissue is relaxed, friable and pale, and
gorged with a serous or sero-sanguineous fluid.  All this will be the more
evident, the more rapidly the tubercular deposit is effected, and the more
the universal cachexia is developed.
  The conditions under which hepatic tubercle occurs, render it apparent
that it rarely passes into  the stage of softening, and scarcely ever into
that of cretification; the constitutional affection generally proves fatal
from  its  violence  and diffusion,  before the  tubercles of the liver have
undergone these metamorphoses.   Still  we do occasionally  find that,
from the very violence of the constitutional affection, a solution of hepatic
tubercle is effected;  and then it  is probably the yellow variety which is
converted into  a primary hepatic vomica, and which  offers no peculiar
characters beyond the biliary discoloration of its contents.
  We do not, however, meet Avith a  condition accompanying tubercular
suppuration in the liver which may be considered analogous to pulmonary
phthisis.
  This vomica  requires to be the more  carefully distinguished from
morbid dilatation of the gall-ducts, as the latter not only occurs frequently
or almost invariably, in combination with hepatic tubercle, but is  not
unfrequently coexistent with tubercular disease of other organs.  In this
case small cavities, of the size of  a millet-seed or a pea, filled with viscid,
muco-bilious, dirty green matter, with flaccid parietes, are found  scattered
through the liver, which on close  examination are found not to  be tuber-
cular, but to be dilatations of capillary gall-ducts.   The hepatic tubercles
exist at the same time, and at various  distances;  a tubercle may occa-
sionally be found near one of these cavities, but it is not  characterized
by the symptoms of secondary deposit accompanying the fusion of tuber-
cular matter.
  The conditions of their origin, and their connection Avith the constitu-
tional disease, have not been as  yet ascertained; but we are Avarranted
by numerous observations in stating, that they invariably indicate a high
degree of the constitutional affection; and  a tendency to universal tuber-
cular deposition, and especially in the abdominal viscera.
  Hepatic tubercle  may be complicated  with  tubercular affections of
almost all organs, as might be assumed from its originating in an advanced
stage of tubercular dyscrasia; however, the abdominal organs are found
chiefly implicated, viz. the abdominal lymphatic glands, the spleen  the
peritoneum, and the intestinal canal. 
THE  LIVER.
121
   e. Carcinoma of the liver.—Carcinoma of the liver is a disease of much
greater importance than tubercular deposition, as it occurs very frequently
and is often a primary affection.
   Although we do not coincide with Cruveilhier, as to the frequency of
its occurrence, it still must be considered  as a common affection, and we
would give its numerical relation to carcinoma of other organs  as one to
five.  The greater frequency of its occurrence, as compared with tubercle
of the liver, and considered  in reference to the frequency of both affec-
tions in other organs, and especially in the  lungs, and to the facts con-
nected with the formation of cysts in the lungs and the liver, is a matter
of particular interest.
   These remarks apply to carcinoma of the liver generally, but not to
its different varieties;  of these, some are frequent, some  occur less fre-
quently, some very rarely.
   Four varieties of carcinoma  are  found  in the  liver, which we  will
examine in succession.
   aa.  Areolar cancer.—This form occurs so rarely, that it is  never de-
scribed among hepatic affections.   One case  of very extensive areolar
cancer has come under my notice.
   (3ft.  Carcinoma fasciculatum sive hyalinum (Miiller). Although not as
frequent as the following, it undoubtedly occurs often. It is generally taken
for medullary carcinoma, and the mistake is accounted for  by the fact
that the two often coexist.   It forms masses of the size of a filbert to
that of a man's fist, which are surrounded by an investment of delicate
cellular tissue; though the surface is uneven and  lobulated, the general
outline is round; its consistency varies, being sometimes but  slight, at
others almost cartilaginous ;  its color a pale  yellowish-red, and generally
of almost vitreous transparency.  The carcinomatous masses  are  com-
monly found  in considerable numbers,  and  like medullary cancer, they
cause rounded  protuberances of the viscus,  and  produce an increase in
its weight and size.
   yy. Medullary  carcinoma.—This is the most common form of hepatic
cancer, and almost all investigations that have hitherto been made in
reference to this  subject, treat of this variety only.  It occurs  either in
the  shape of  detached  masses, or  as an  infiltration  of  the hepatic
parenchyma.
   aaa. The detached  masses occur as tumors, which offer many peculiar
features.
   Their general form is spherical, though their surface not unfrequently
is slightly racemose or lobulated.  Those AYhich have been developed in
the peripheral portion  of the  organ, and are therefore in contact with the
peritoneum, present  a flattened, or even  an indented surface, and the
indentation may extend to the very nucleus  of the morbid growth.  The
peritoneal lamina in the indentation is opaque and thickened, owing, not
as is commonly thought, to cartilaginous  induration, but  to an homolo-
gous cancerous degeneration  of the  serous and subserous tissue.   This
condition of the peritoneum  is analogous to the  relation the  common
integument bears to subjacent cancerous growths.
   In size the medullary cancer varies from that of a millet- or hemp-seed
to that of a man's fist, a child's head, and  more.   In most instances mor- 
122
ABNORMITIES  OF THE
bid growths of various sizes are found in the same individual.  The larger
those are which  occupy the peripheral portion of the organ, the more
prominent will be the protuberances on the surface.
   The number of these adventitious products varies equally; sometimes
there are but few, or even only a solitary one is found;  at others  they
are very numerous.  The greater the number of those occupying the
peripheral portion of the organ, the more numerous will be the protube-
rances on  the surface.  When the morbid  growths  are  numerous and
large, two or more often coalesce.
   We are unable to discover any peculiarity in reference to their  posi-
tion ; they commence equally in the peripheral and in the  deeper-seated
portions of the intestine.   They commonly make their  first appearance
in the right lobe.
   As regards consistence, we find two varieties  which  have also  been
considered as differing in texture.   They  do  not, however, constitute
essential distinctions, but are merely different degrees of development of
the same morbid growth.
   One is of the  consistency of bacon, and presents on section a smooth
homogeneous, shining surface, of a dull white color, and without a trace
of bloodvessels.   On pressure, a small quantity of a  thick creamy fluid
exudes from the  meshes of a dense fibrous structure.   These growths are
not detached from the  adjoining hepatic tissue without considerable diffi-
culty ; and a distinct cellular  investment  can scarcely be demonstrated.
The growths belonging to this variety, when coexisting with the second,
are always the smaller of the two.
   The second presents the physical characters of true encephaloid dis-
ease ; its  general  color  is milk-white, it is more or less vascular, and
consequently in  part gray,  yellow, brownish, red, or even dark red; it is
very spongy, and on pressure yields a  large quantity of  a  thin milky
fluid, which is contained  in the meshes of a friable, fibrous tissue.   The
tumors are invested by a delicate cellulo-vascular sheath, and are easily
detached from the hepatic parenchyma.  When occurring simultaneously
with the first variety, they  generally form the large morbid growths.
   The latter evidently represent an advanced stage of the morbid growth,
as appears notonly from the foregoing remarks, but also from the rela-
tions of the primary cell. (Vide vol. i.)
   /5/9/9. Infiltrated medullary cancer is analogous to the other infiltrations
of the hepatic tissue, which we have already discussed.   It always con-
tains obliterated and obsolete bloodvessels and gall-ducts, which are gra-
dually absorbed.  The infiltration attacks larger or smaller segments of
the viscus; it does not present distinct boundaries, but insensibly passes
into the normal parenchyma.   It rarely occurs Avithout nodulated cancer.
The carcinomatous mass  presents the same two  varieties in reference to
consistence and  to its elementary constitution.  We find a transition
from the diffused to the circumscribed form  in the fact, that the nucleus
of the latter is sometimes  infiltrated  hepatic tissue, which becomes en-
dowed with independent growth, and merely forces the parenchyma out
of its place.
   The larger and the more numerous  the  carcinomatous masses are the 
BILIARY  PASSAGES.
123
more extensive the cancerous  infiltration, the more  does the viscus in-
crease in size and weight.  The extracancerous tissue presents the nutmeg
and adipose degeneration.
  Medullary cancer is here, as elsewhere, the seat of hemorrhages, Avhich
are proportioned to the rapidity of its groAvth and the looseness of its tex-
ture.   In rare cases it penetrates  through the peritoneal investment of
the liver, its development then proceeds with extreme energy, and it in-
duces exhausting hemorrhages.  In other cases it perforates the coats of
large gall-ducts within, or of the biliary passages external to the liver,
and grows into their cavities.  In the infiltrated form we not unfrequently
find extravasations of bile to a greater or less amount.
  Medullary cancer rarely passes  into suppuration, as it generally termi-
nates fatally by inducing universal cachexia and exhaustion.   Its fusion is
still more rarely found  to take place within  a fibrous sheath, as is  com-
paratively oftener the case in the  spleen.  Occasionally nature seems to
attempt  an arrest of the  morbid growth, by a conversion into fat or
adipocire.
  Hepatic cancer undoubtedly very often occurs as the first of a succes-
sive series of cancerous deposits; yet, in the dead subject, it  is commonly
found combined with carcinoma  of the lymphatic glands, that are seated
near the biliary passages and in the lumbar region, Avith cancer of the
stomach, of the intestine (especially of  the rectum), of the peritoneum,
of the  kidneys,  and with universal cancerous  infection.   It is often
developed  with remarkable rapidity after the extirpation of cancerous
groAvths, and is then generally accompanied  by cancer in the lungs.
  yyy. Medullary carcinoma not unfrequently occurs in the  liver in the
shape of cancer melanodes (melanosis),  and equally as an infiltration, or
in circumscribed masses.  We find the most varied  combinations of its
elementary molecules with those of pure medullary cancer.
  A common result of hepatic cancer making its way outwards, is inflam-
mation of the peritoneum;  the carcinomatous liver is consequently often
found agglutinated to neighboring parts  by means of cellular or  cellulo-
fibrous tissue, which may in its turn be subjected to cancerous degenera-
tion.

         SECT. II.—ABNORMITIES  OF THE BILIARY  PASSAGES.

  We now come to the consideration of the diseases of the gall-bladder
and its efferent duct, those of the ductus communis choledochus, of the
ductus hepaticus, and of the branches and ultimate distribution of the
latter.   We include  the entire  apparatus under one  head, though _ we
shall devote a special consideration to the peculiar characters exhibited
by separate sections.

  §  1. Excess and Befect of Formation.—In  rare cases  a congenital
absence  of the  gall-bladder has  been  noticed, an anomaly which must
not, however, be confounded with obliteration of the gall-bladder which
is frequently consequent  upon inflammation.   When there are  two
liAxrs, the gall-bladder and the entire apparatus correspond ; but we also
find, without any further anomaly, a twofold instead of a single common 
124
ABNORMITIES  OF  THE
duct; the two ducts then either both open into the duodenum, or one
communicates with the duodenum, and the other Avith the stomach.

  §  2. Irregularities of the Biliary Passages with reference to  Calibre.
—Independently of congenital enlargement or diminution of these parts,
we find important acquired anomalies in  the shape of dilatation or  con-
traction.
  Dilatation either affects the entire apparatus from the duodenal orifice
to the capillary gall-ducts equally or  almost  equally, or  it only affects
larger or smaller portions, whilst the remainder retains its ordinary size.
The  gall-ducts are capable of extreme distension.
  We find that dilatation of the passages is caused by habitual accumu-
lation of  inspissated bile, and by everything that impedes the progress
and the discharge 6f the secretion.   We allude  to  compression of the
biliary passage within and external to the liver by morbid products or
enlarged  lymphatic  glands, to diminution of their calibre by tumefaction
of the coats, by cicatrices  or  unusually large  folds  or  valves of the
mucous membrane; to obturation by biliary calculi, by morbid  growths
projecting into the cavity of the biliary passages, by catarrhal or croupy
secretions.   Some of  these  obstacles occur mainly in one, others  in
another  portion of the apparatus.   If  the  impediment  occupies the
ductus choledochus, the dilatation gradually extends over the entire ap-
paratus ;  but it must be observed that the dilatation of the gall-bladder
does not  in general  correspond  with the dilatation of the other portions,
as its efferent duct (ductus cysticus), .from  opening into the common
duct at  an  acute angle, is compressed  by the  enlarged ductus chole-
dochus.   The more completely the calibre is  obstructed, the more  com-
plete is the  capillary distension; the more rapidly it ensues, so as not
unfrequently to induce rupture.
  The ductus choledochus is either found  compressed by disorganized,
and  especially by cancerous, lymphatic glands, or by the pancreas,  or
the passage  is narrowed by the tumefied mucous membrane  or by the
tumefied  valve, or it is closed up by a biliary calculus or a carcinomatous
tumor from  without.  Occasionally it is so enormously dilated as to ex-
ceed the  diameter of  the small intestine; the slower this  effect is pro-
duced, the more marked will be its active character; and the distension
extends upwards, passing by the gall-bladder, as above observed, to the
hepatic duct and its ramifications.
  The channel of  the ductus  cysticus  is  found impaired by  unusual
flexures,  or  large and numerous mucous folds, consequent upon previous
elongation and distension, by cicatrices and cancerous degeneration ; it
may become  perfectly obliterated  by the  same means,  or by biliary
calculi, which  are  impacted in  the  neck, and  more particularly in a
lateral dilatation of the gall-bladder.  Enormous dilatations of the latter
result, which in the course of time induce an entire change in the tissue
and  the functions of the mucous membrane of the gall-bladder.
  After  this occlusion has been rendered complete, the residuary bile in
the gall-bladder is absorbed; the mucous membrane secretes mucus more
copiously, in proportion to the irritation exerted upon it by the stagnating
mucus left  after the removal of the  specific  contents of the bladder.
The secretion gradually accumulating, the gall-bladder  extends, and 
BILIARY PASSAGES.
125
its mucous membrane becomes converted into a serous membrane, which
secretes a  serous, albuminous fluid, resembling synovia;  this is at first
opaque, and subsequently becomes  clear, and we  detect  in it, with the
assistance of the microscope, nothing but solitary flocculi  of pigmentary
matter, and a few  crystals of biliary  fat.   This  affection of the  gall-
bladder is termed hydrops cystidis felleae, and the  bladder resembles the
sound  of fishes, being  converted  into  a  tense  capsule,—a condition
similar to that developed under analogous circumstances in the Fallopian
tubes, the ureters, the pelves and calices of the kidneys, and  even in the
vermiform  process.
  The new lining membrane of the gall-bladder is  subject to  all the dis-
eases to AA'hich serous membranes and their cavities are liable  ; inflamma-
tions occur  very frequently, giving rise to the  most various  exudations,
and  terminations as  various.  Among the latter, we allude especially to
shrivelling of the gall-bladder, accompanied by diminution  of  its  con-
tents.   These become inspissated, so as to form an adipose chalky pulp,
or chalky concretion, with a subsequent ossification of the parietes.
  The dilatation of the biliary  ducts in the interior of the liver  is either
uniform, and affects  the  entire  organ or certain portions  only, or it
occurs as a partial saccular dilatation of one or more of those ducts.   In
the former case the cause is generally to be  found in an obturation of the
biliary channels within or external to the liver, by means  of concretions,
cancerous  growths,  or croupy exudation;  and the  dilatation very fre-
quently extends  from  the ductus  choledochus to the  biliary passages
within the liver.   In well-marked cases the entire capillary network be-
longing to this apparatus  is  dilated and gorged with bile;  the paren-
chyma of the liver may be saturated with bile, and  present a dark yellow
or green color; the viscus is turgid, though  pulpy and friable, resembling
the  condition of  yellow atrophy; the larger ducts  contain bile in a dis-
organized state, and not unfrequently blood in a similar condition.
  This affection  invariably proves fatal with  symptoms of biliary infec-
tion of the  blood,  and  consequent  cerebral disease, which  is  often
combined  with  exudation on the  arachnoid, with  intense  icterus and
extreme pain in  the liver.  The capillary ducts  are occasionally  rup-
tured, and this  gives  rise to larger or  smaller accumulations of bile in
the  deep-seated portions of the organ ;  or the rupture may occur in the
peripheral  layers,  at  spots where  patches of dilated  gall-ducts  form
rounded, fluctuating projections on the  surface of the organ; in this case
the hepatic peritoneum frequently becomes involved, and extravasation
may take  place into  the abdominal  cavity.  Finally,  the bile  that
transudes through the coats  of the gall-ducts may, if it reaches the peri-
toneum, induce  peritonitis, which in its turn  predisposes to rupture of
the  serous  covering investing the approaching  biliary abscess.
  The  second or saccular  form of dilatation of the  biliary ducts is
generally the result  of a catarrhal or blennorrhoic condition.  Capsules
varying  in size from a pin's head to a hen's  egg, with a loose  mucous
lining that forms  valvular folds, are found  scattered  through the liver,
and  they contain a liquid consisting of blennorrhoic or purulent mucus
and  bile, which deposits a sediment or incrustations.   The character of
the investing membranes affords a sufficient distinction from other cavi- 
126
ABNORMITIES  OF THE
ties containing a similar fluid ;  but the afferent and efferent canal is not
easily discoverable, even Avith the assistance of injections.   These dilata-
tions  undoubtedly originate in an  accumulation of catarrhal secretion,
and are generally accompanied by a dull pain in the liver.
   Contraction of the biliary passages is  induced by the above-mentioned
circumstances, and  may advance  to adhesion  and obliteration, as is
especially the case in the gall-bladder.

   § 3. Anomalies in  the  Form and Bisposition  of the  Biliary Pas-
sages.—Among these we reckon the various congenital malformations of
the gall-bladder, in which it presents an  intestinal,  cylindrical, extended,
twisted,  pyriform,  or phial-shaped appearance, or in which it seems
divided longitudinally or transversely, owing to a rigid condition of the
internal folds.   To this class also belongs the anomalous insertion of the
ductus choledochus into the duodenum or stomach.  The  acquired mal-
formations consist in contraction, obliteration, or dilatation of the  gall-
bladder ; in change of position of the  biliary passages, owing to pressure
exerted upon them by enlarged lymphatics, morbid growths, &c.

   § 4. Solutions of Continuity.—We regard  as peculiarly  interesting
the spontaneous ruptures  occurring in the biliary passages external and
internal  to  the  liver as a consequence  of  excessive dilatation, which is
generally preceded or accompanied by  inflammatory action.  We  have
also to cite the perforations of the biliary passages external to the liver,
resulting from suppuration of their  coats, and the abnormal passages
subsequently established between the biliary ducts and the stomach and
intestinal canal; as well as certain abscesses produced by suppuration of
the capillary gall-ducts within the liver,  of which we shall have occasion
to speak  more fully in the sequel.  (See  Textural Diseases of the Biliary
Passages.)

   § 5. Textural Biseases.   a. Inflammation.—We often observe catar-
rhal inflammation occurring in the  biliary  passages, with various termi-
nations and results.  Like catarrhs of other mucous membranes, it not
unfrequently is a primary affection, and  becomes chronic, or it as often
is propagated from the intestine to the gall-ducts;  but it often evidently
has its origin in the  irritation caused  by an accumulation  or an altera-
tion in the composition  of the bile, and especially by biliary calculi.   At
the bedside the affection is undoubtedly often mistaken for irritation and
inflammation of the hepatic parenchyma.
   OAving to the paralytic state induced   in  the contractile  and irritable
layer of their coats,  and to the accumulation of bile, the gall-ducts become
distended, their mucous membrane relaxed and tumid, and the muscular
coat hypertrophied ; within the liver saccular dilatations are formed  • the
catarrhal disease induces a stagnation of bile, Avhich gives rise to calcu-
lous concretions, and occasionally suppuration and perforation of the gall-
ducts follow.  In the range of  the  biliary capillaries  it most probably
causes, in the manner just  described, the formation of peculiar accumula-
tions (abscesses), which are remarkable for the blennorrhoic pus and the
bile they contain, and are thus distinguished from the products of paren-
chymatous inflammation of the liver. 
BILIARY  PASSAGES.
127
  Inflammation originating in irritation, caused by biliary calculi, de-
serves a special consideration, on account of its terminations and its con-
sequences ;  it occurs chiefly in the gall-bladder.   Occasionally and par-
ticularly when brought on by an accumulation of bile from obturation of
the neck of the  bladder or of the ductus cysticus, it runs a  very rapid
course, attacking the submucous tissue of the gall-bladder, and terminat-
ing in rupture and effusion of its contents into the peritoneal cavity.  At
other times it proceeds more slowly, and after repeated relapses, induces
suppuration and ulcerative perforation of the  gall-bladder.   The  latter
is most liable  to occur at the dependent  portion, which is chiefly exposed
to irritation, viz. the fundus of the bladder; and as previous peritoneal
exudation will have agglutinated it to  adjoining viscera,  the suppuration
extends to them, giving rise to abscesses in the liver itself above the gall-
bladder, or in the lesser omentum;  or establishing  fistulous  passages
through the abdominal parietes,  or communications  between  the  gall-
bladder and the pylorus, the duodenum and the transverse colon.   Lastly,
in favorable cases, the coats of the gall-bladder may be  converted into a
fibrous, callous tissue ;  its contents are discharged by  the normal  or by
the above-described anomalous passages, and the organ represents a thick-
coated hollow capsule, with  or without  cicatrices on  its inner surface,
and containing, according to the condition  of the mucous membrane, a
mucous or serous fluid, and not unfrequently one or more calculi.   This
is the so-called obliteration or atrophy  of the gall-bladder.  The  calculous
inflammations of the biliary passages are  followed, though less frequently,
by similar results, viz. rupture, suppuration, gangrenous perforation, cal-
lous induration, and obliteration.
   b.  Croupy  inflammation is  of very rare occurrence.  We  have ob-
served it in the mucous membrane of  the gall-ducts in the liver, accom-
panying cholera-typhus and ileo-typhus. It gives rise to tubular exuda-
tions,  in which the bile forms branched  concretions which block up the
passages, and thus cause dilatation of the capillary gall-ducts.
  We have already noticed the occurrence  of the secondary and gangre-
nous typhous  process on the mucous membrane of the gall-bladder.
  c.  (Edema  of the coats of the gall-bladder.—Serous infiltration of the
coats  of the  gall-bladder occurs  in  general  dropsy, and  especially in
ascites, and also in the shape of subserous infiltration in inflammation of
the peritoneum.
  d.  Adipose deposits  in the  coats of  the gall-bladder.—An  excessive
deposit of fat under the  peritoneal investment of the gall-bladder only
occurs as an accompaniment of general adipose accumulation, or at least
of accumulation of fat in the abdomen.   Its occurrence is of some inte-
rest, inasmuch as, like the fatty deposit  in  the heart, it is likely to in-
duce fatty degeneration of the muscular layer.

   § 6. Adventitious Products,   a. Fibroid tissue.—Under this head
we  class the textural alteration occurring in atrophy of the gall-bladder
after inflammation.
  b.  Anomalous  osseous deposit—ossification, as elsewhere  in mucous
canals, takes  place only as  a consequence of previous textural alteration
of another kind.  Thus we find subserous osseous lamellae formed in the
parietes of the gall-bladder, after it  has  been  converted into a sero- 
128
ABNORMITIES OF THE
fibrous capsule, in hydrops cystidis; or the fibroid tissue which is deve-
loped in the parietes of the gall-bladder, as a consequence of inflamma-
tion and partial suppuration, may ossify.
   c. Tubercular deposit in the  biliary passages  is  of  very rare  occur-
rence.
   d. Carcinoma  of the biliary passages is  chiefly met with asa compli-
cation of cancer of the liver,  but also of the lumbar lymphatic glands,
and of the stomach.  It occurs  either as an idiopathic nodulated deposit
in the submucous tissue, in rare  cases giving rise to annular stricture and
degeneration of the entire bladder into a  cancerous  capsule, or as can-
cerous infiltration of the mucous membrane; or, as is  more commonly
the case, the biliary passages are  attacked from without, cancerous growths
in the vicinity perforate the parietes, and push their way into the cavity.
The gall-bladder  is  most frequently attacked by hepatic cancer; the
ductus  choledochus  by carcinoma  of  the lymphatic glands.   Obtura-
tion of  the passages and hemorrhage are  common consequences  of the
affection.

   § 7.  Anomalous Contents of the Biliary  Passages.—The most remark-
able are those entirely abnormal contents of the  biliary passages, which
are either the product of textural changes  and morbid processes in their
coats, or which after being generated externally, are conveyed into the
cavity by  Ararious passages.   We allude to the sero-albuminous fluid of
dropsy of  the bladder, to mucus, to  pus that has been formed  in the
biliary passages, or in hepatic abscesses, to blood derived from cancer-
ous growths, to acephalocysts from the liver, lumbrici  from the intes-
tine, &c.
   The bile itself presents great varieties as to quantity, but more still
as to quality; in the majority of instances the  anomaly has its  origin
not so  much  in  disease of  the liver, as in morbid conditions of other
organs,  especially of the intestine and of the portal blood.
   As regards quantity,  the bile  is found accumulated to a  large amount
in the biliary passages and intestine, or  it is remarkably scanty.  It is to
be observed that in the  latter case the deficiency is  sometimes  compen-
sated by the saturated condition of the fluid.
   The qualitative anomalies of the bile are more numerous  and impor-
tant, and  affect both its physical and its chemical constitution.
   The color of the bile  varies extremely: it may  be  pale yellow, ochrey,
orange-colored, yellowish-brown,  blackish-brown, black, or of all the
different shades and tints  of green.  The consistency of  the bile gene-
rally increases in a ratio with  the  increased  depth of color,  varying
from the fluidity of water to  the density of tar and of calculous concre-
tions.   In taste it Araries as to the amount of bitterness, but it may also
be more or less, or entirely, saccharine, saline, sour, alkaline  acrid  or
insipid.
   In reference to  its chemical constitution, the bile presents, as might be
inferred from its physical qualities, numerous deviations from the correct
standard; the  chief constituents vary in their relative proportions  or
they are replaced by new anomalous substances.
   The biliary calculi are of considerable importance.   They originate in 
BILIARY  PASSAGES.
129
a morbid constitution of the bile, which may be abnormal when secreted,
or subsequently become so from  stagnation  and retention.   They occur
in the biliary passages external  to and within the liver, but more espe-
cially in the gall-bladder.
   Here too we find numerous variations with regard both  to  physical
qualities and to chemical composition.
   They vary in size from a millet-seed to a hen's  egg, and  more.   We
generally find the largest to be formed by several materials  disposed in
layers, with a preponderance of fatty matter.  The larger they are, the
less numerous will they be; sometimes several hundreds of small calculi
are discovered in the gall-bladder.
   Their form  and surface vary much.   Single calculi  are commonly
round, oval, or cylindrical; when very large, so as to occupy the  entire
cavity of the gall-bladder,  they are frequently slightly curved; if several
are present at the  same time, they mutually prevent their enlargement,
and in consequence  of the friction and pressure they exert upon one
another, they assume cubical, tetrahedric, prismatic, or irregularly poly-
hedric shapes, with convex or concave surfaces.
   The calculi found in the ducts are generally cylindrical,  occasionally
branched, or entirely amorphous.  Their surface may be smooth and unc-
tuous to the touch, or rough, racemose, uneven, of a mulberry appearance,
crystalline, or branched.
   The texture of the calculi may be uniform or varied, in proportion as
they consist of one substance, or of several layers.   Many show no dis-
tinct  arrangement;  some have  an  earthy pulverulent  fracture, or a
fibrous, striated, laminated, micaceous texture, presenting a glassy, silky,
or asbest-like gloss  on fracture, as  is particularly observed in calculi
consisting of cholesterine.
   Generally speaking,  they are  not very hard, and may, Avhen first  re-
moved from the body, be easily compressed between the fingers.  On
drying, they crack  and fall to pieces, and, at last  become  pulverulent,
which is particularly the case with those concretions which consist of in-
spissated bile or biliary resin.
   In  color  they vary  considerably;  they  may be milk-white, bluish,
chalky, light or dark-yellow, brown,  black, or colorless, or  transparent,
with a  slight yellow or green tinge.  Those of  an ochrey, red, green,
and blue (bronzed) color are unusual.  Sometimes we find them spotted,
and either of a  uniform color throughout, or varying in layers, or at
least containing a differently colored nucleus.
   Chemical analysis shows the  biliary calculi to consist mainly of in-
spissated  bile, biliary resin, coloring and fatty matter, and  the calculus
may be either formed of one of these  substances  or of a mixture of
several.   In the latter instance  they either interpenetrate one another,
or are  disposed  in  distinct  layers, which  are distinguishable  by their
color or texture.
   Large biliary calculi generally contain but a small portion of inspis-
sated bile; the latter  often  forms small irregular concretions  in the
gall-bladder, or larger cylindrical and branched concretions in the gall-
ducts, or it serves as a  nucleus to the  various calculi of the gall-bladder.
The resin and pigmentary matter of the bile enter  into the composition
   VOL.  II.                          9 
130
ABNORMAL  CONDITIONS
of the majority of gall-stones,  and that frequently to a  considerable
extent.
  Cholesterine almost always preponderates ; it frequently occurs in a
pure state as  a white, mother-of-pearl like, shining, or opaque fatty in-
vestment, or in distinct layers of a striated texture, which are separated
by colored resinous layers ;  it may also exist in an isolated form, depo-
sited round a colored nucleus, and give rise to translucent calculi of a
striated and distinctly crystalline  texture.   In  the latter case we gene-
rally find that small  solitary calculi, in the former very large calculi
result.
  Picromel commonly occurs but in minute quantities, in biliary calculi;
the various salts they contain form but  a small  proportion  compared to
the amount of the above-named constituents.  Those concretions in the
gall-ducts which are found to consist of carbonate of lime,  are not pro-
ducts of the bile, but of the blennorrhoic mucus and pus of the gall-
bladder.
  The calculi found in the same gall-bladder generally resemble one an-
other in composition,  shape,  and size ; although we meet with occasional
exceptions from this rule.  Thus in dropsy of the  gall-bladder, we often
find, beside the calculus which closes up the  cystic duct, and which is of
an old  date, and of complicated structure, a  second crystalline calculus,
of more recent formation, which consists of pure cholesterine.
  The calculi  are either unattached or sessile.   In the latter case they
may be grasped and retained by a portion of the bladder, or be aggluti-
nated to its internal  surface by exudation, or they may be included in
compartments, formed by an inspissated albuminous product of the gall-
bladder, or by organized lymph which has been converted into fibrous
tissue.   Small calculi are also occasionally formed within small saccular
dilatations of the biliary mucous membrane, and may appear to lie  ex-
ternal to the cavity of the bladder.
  Biliary calculi frequently cause irritation, inflammation, and subse-
quent suppuration of  the coats of the gall-bladder, which may terminate
in various ways.   Cicatrices are often left, which more or less diminish
the cavity.  They may  induce  complete occlusion  of the  biliary pas-
sages, followed by dilatation and retention of bile.   We must, however,
observe that sometimes,  owing to the extreme  distension which the
biliary passages  are capable of, calculi of the size  of a hen's egg are
enabled to pass.
  Biliary calculi  are  of common occurrence.  We have observed that
their formation is peculiarly coincident with excessive deposit of adipose
tissue and with carcinoma.
  The entozoa occurring in  the human gall-bladder are the endogenous
acephalocyst of the hepatic parenchyma and  the distoma hepaticum.

        SECTION  III.—ABNORMAL  CONDITIONS OF  THE SPLEEN.

  § 1.  Befect and Excess of Formation.—The spleen is generally absent
in acephalous monsters, together with other organs of the abdomen and
thorax.  Occasionally it is found wanting, together with the stomach or
the fundus of the  stomach, in subjects that are otherwise well developed 
OF  THE  SPLEEN.
131
or it exists in a rudimentary state, whilst  the  stomach is in a normal
condition.   The explanation of these phenomena is to be sought in the
history of the development of the embryo.
   The spleen is found double in biventral monstrosities.  The multipli-
cation of the  spleen, in  the shape of lienes succenturiati, is not to be
vieAved as an increase, but as a subdivision of the organ, which does not
affect  its individuality.  We  not  unfrequently find, besides the main
organ, small accessory spleens (lienes succenturiati) seated in the omen-
tum and ligamentum gastrolienale.   They vary in size from that  of  a
millet-seed  to that  of a walnut, and in number from one  to twenty.
They are round, present the same structure as  the  spleen, and are  mor-
bidly affected  at the same time, and in  a similar manner as the latter.
The marginal indentations of the  spleen, or the complete separation of
a  portion of the organ by a horizontal fissure, form transitions to this
abnormal condition.

   § 2. Beviations of Size.—Deviations of size consist either in an abnor-
mal increase  or diminution of the  organ.  The former is of particular
importance, and those tumors afford a special interest, which depend
upon congestion caused not  by mechanical impediments, but by the
peculiar relation of a morbid state of the blood  to the spleen.  With the
rare exceptions  of those cases  in  Avhich, like  analogous states of the
liver,  they  are  congenital,  these  conditions are acquired.   They are
either acute or chronic : in  the former case they accompany  other acute
diseases, either during their entire course,  or only during single stages;
in  the latter,  the  tumefaction results from dyscrasiae or cachectic con-
ditions, which induce congestion, induration,  and  hypertrophy of the
spleen.  These terms, however, from referring mainly to external ap-
pearances, are apt to cause the real nature of the disease  to be over-
looked.
   It is unnecessary to enter  more fully into the consideration of these
changes affecting the splenic parenchyma, which are evidenced by tume-
faction, as it will  be more  appropriate  to treat the  subject under the
head of Textural Diseases.  We merely add the following remarks  :
   a. Acute  tumefaction is generally accompanied by considerable soften-
ing of the splenic parenchyma ;  chronic tumefaction by increase in the
consistency  of the organ.  It is questionable whether the hypertrophy
affects the elementary tissue and constitution  of the  spleen:  this  is  a
point which  requires  to be elucidated by. further research ; but there is
no doubt of  the fibrous trabeculae  of the spleen and  its fibrous capsule
becoming hypertrophied in old chronic tumors.  When  we have  suc-
ceeded in reducing an acute or chronic tumor, or even a mere hyperaemic
state of the spleen, we often  find the sheath  of the spleen thickened,
opaque, corrugated, and relaxed after death—a fact which may serve as
a useful indication.
   b. The size attained by chronic  tumors of the spleen is  often  very
considerable.  The spleen not unfrequently measures  sixteen inches in
its long, seven inches in its short diameter, and  four inches in thickness;
its weight may amount to thirteen pounds and  a quarter, and, according
to the observations of others, even to twenty and more pounds. 
132
ABNORMAL  CONDITIONS
  Diminution of the spleen is characterized by^ shrivelling of the fibrous
tissue, which prevents the vessels from being injected ; and is peculiar
to genuine cholera (cholera algida), or it  occurs  as  atrophy, in conse-
quence of a special change in the fluids at large. _  Under this head we
must class numerous obscure cases of permanent diminution of the spleen
in individuals who in no way resemble each other, of the  reduction of
the spleen  observed by some pathologists  as  resulting from the use of
steel,  and of the senile inArolution of the spleen.
  Atrophy varies in degree;  it occasionally advances to such an extent
during the involution of the organ, as to reduce  it to the size of a hen's
egg or walnut.
  The spleen  in these cases is  paler than usual, its  consistency is in-
creased or diminished, the  organ may assume the toughness of leather,
or become soft, friable, and pultaceous.  Senile  atrophy may be charac-
terized in the  following manner :  the spleen is  considerably reduced in
size, and flabby; its sheath is opaque, corrugated and thickened, but at
the same time softened and easily ruptured; the parenchyma consists of
a pulp which is of the color of rust or the lees of wine, and which is en-
closed in  dense and equally friable, fibrous tissue.   We not unfrequently
find the sheath of the spleen indurated and cartilaginous, or  ossified,
and at the same time, ossification of the arterial ramifications and free
calcareous concretions (phlebolithes) in the veins of the organ.

  § 3. Beviations of Form.—We not unfrequently meet with a tongue-
or platter-shaped, almost cylindrical, globular, or angular spleen;  its
edges may be more or less notched,  which  is particularly the case with
the anterior margin ; and the indentation  may extend so  far as to cause
a transverse  division  of the  organ.   These furrows  are  not to be con-
founded with the contractions that are occasionally produced by inflam-
mation and metastasis, and which very much resemble the former.

   § 4. Beviations of Position.—The congenital  anomalies  that come
under this head consist in the spleen occupying a place  external to the
abdominal  cavity, when the latter is fissured, in its being placed in
large  umbilical  herniae,  and in  the left thoracic cavity  when  the  dia-
phragm is absent, and in a varying position, consequent upon an anoma-
lous congenital elongation of the peritoneal attachments.
   Acquired  deviations  of position  consist in a descent  of the spleen,
when forced doAvn by enlargement of the left side of the thorax, or in its
being pushed up by dropsical and ascitic accumulations, or by a tympani-
tic state of the intestine ; in its  dislocation by various tumors or in its
descent from increase in size  and weight.  Enlarged spleens  sink  ver-
tically into the left mesogastric region, or  raise the diaphragm, or they
descend  to the ileum, and in the  case of a still  further increase of size
slide  off from the  latter, so as to occupy a diagonal position in the hy-
pogastrium, and extend over the right ileum.   There is  no doubt  that
the spleen  occasionally presents very loose  attachments  and remains
freely movable, even  after it has been reduced from a hypertrophied
state to its normal size, in consequence of  the previous traction exerted
upon its ligaments. 
OF  THE  SPLEEN.
133
  §  5. Solutions of Continuity.—Under this head we class injuries of
the spleen  inflicted by  cutting instruments, rupture consequent upon
blows or knocks received in the region of  the spleen, contusions, as in
being  run over, concussions,  as  in  a fall, and spontaneous  ruptures.
The latter are of peculiar interest,  as they are the result of acute and vio-
lent tumefaction of the organ, proceeding to a most intense degree.   We
are able  to confirm the fact observed by other authors, of the occurrence
of spontaneous  rupture  in typhus, in typhoid cholera, and in the hot
stage of ague, and the consequent fatal termination from hemorrhage.

  §  6. Biseases of Texture.—The chief diseases that  appertain to  this
class, the hyperaemiae, the so-called infarction and hypertrophy, and in-
flammation of the spleen, require,  in  order to be duly appreciated, not
only anatomical proof of the existence of the disease, based upon a clear
notion of the structure of the organ, but more especially an advance in
our knowledge of the pathology of the blood and the serum.   Numerous
diseases,  and more particularly the simplest derangements,  as many
cases of  hyperaemia, can only be elucidated by attending to these points.
These diseases of the spleen are probably  but  rarely idiopathic; they
almost always arise from certain anomalies of the blood  and the serum,
or from  certain dyscrasiae, which,  though little known, and as little un-
derstood, bear a remarkable and  positive  relation to  the spleen.   The
spleen may in fact be considered as the most sensitive  test for a variety
of dyscrasic states of the fluids.   An  acquaintance Avith  this connection
may serve to lift the veil which still conceals the true function of this
organ.   We shall now resume the consideration of tumefaction of the
spleen, upon the basis of the above  remarks, and enter  into a more
minute investigation of  the subject than we could adopt in the previous
general outline.  The main points relating to deviations of consistency will
at the same time be adverted to.
   1. Hyperaemia, ancemia.—Hyperaemia of the spleen arises either from
a mechanical impediment in the circulation of the blood, or from the pe-
culiar relation alluded to as existing  between  the spleen and certain
anomalous conditions in  the fluids.
   The first variety occurs in organic diseases of the heart and in hepatic
obstructions, though not, especially in the  former, to the extent, nor as
frequently, as might be expected  from obstacles or  stasis affecting the
entire system of the vena cava and venae  portae.  The deranged circu-
lating fluid appears to have no  affinity for the tissue of the spleen, and
to be thus in part carried off, and in part  mechanically retained.  This
latter portion, in the first instance, induces a hyperaemic  turgor  of the
organ, and gives it a  dark-red color, and subsequently, as is generally
the case in these hyperaemiae, induces  hypertrophy of  the fibrous tissue
and of the pulpy parenchyma of the spleen.   The organ is more consis-
tent, indurated, and dense.
   The  second  form  accompanies various  dyscrasic  conditions of the
fluids, and in proportion to their  duration induces an  acute or chronic
tumor of the spleen, which differs in appearance, and in its primary and
secondary constitution, according  to the nature of the cause.
   The hyperaemiae affecting the peripheral portion of the organ not un- 
134
ABNORMAL  CONDITIONS
frequently degenerates into inflammation of the peritoneal investment of
the spleen;  the resulting exudations are converted into the cellular,
cellulo-fibrous, or cartilaginous tissues and adhesions, so often found upon
spleens that have formerly been tumefied.
   Anaemia of the spleen occurs in connection with the above-mentioned
reductions in size.
   2.  Tumors of the Spleen.—We have already discussed the tumors of
the spleen arising slowly or rapidly from hyperaemia^ and from the con-
gestion of dyscrasic blood, as far as regards the mere increase of volume.
We have now to examine them more closely in other points of view.
   These tumors are observed in typhus, and in many typhoid states, as
in cholera typhus, in pyaemia, and in anomalous exanthematic processes,
as occurring from disorganization of the blood after erysipelas, scarlatina,
miliaria, or rheumatism, as found in drunkards, and in acute tubercular
affections  ; they  occur as a  result of suppressed menstrual or hemor-
rhoidal discharge, of intermittent fever, of rickets, of lues and mercurial
cachexia,  and of many dyscrasic tubercular affections.
   These tumors differ in character, and are owing  partly to the hyper-
aemia,  partly to the  deposition  of an  anomalous fibrous  product in
the parenchyma  of the spleen.  We find  the  greatest difference  in
the consistence  of  the tumors ;  but the chronic indurated  tumors,  are
undoubtedly  soft  at first, and subsequently attain greater hardness,
according as the deposit is more or less coagulable.  The same remark
applies to the color of the tumor, which at first is undoubtedly red, but sub-
sequently becomes paler in proportion as the coloring matter is absorbed,
and the hyperaemia is forced to yield to the compression exerted upon it
by the deposit.   We find, as  regards other qualities, that the morbid
product offers very prominent  varieties, which we  will  examine in  the
analysis of the chief tumors that folloAvs; the finer, though not less different
characters Ave leave to another department of science, which, though not
yet cultivated, promises many and very important results.
   a. Among the tumors which accompany acute diseases of the blood,
those of typhus are distinguished by their rapid and extensive increase,
by their lax  tissue, both of which circumstances sometimes predispose
to rupture, and by the  dark-red color of the parenchyma.   This variety
originates in  stasis affecting the vascular system of the fundus ventriculi,
and in the deposition of a very lax,  pultaceous, semi-fluid, blackish-red,
dirty violet, or lighter-colored purplish mass, varying in amount, and re-
sembling the  pulpy medullary matter found in the typhous mesenteric
gland.  If this substance  is  deposited rapidly to a large  amount, the
fibrous trabeculae of the spleen are rendered soft and friable by exten-
sion ; and if the deposit is very soft,  the viscus presents fluctuation.
   The tumors occurring in the other acute dyscrasiae above alluded to,
are more  or  less allied to this  one.   When  accompanying universal
acute tuberculosis, the  eliminated mass, partially at least,  at once as-
sumes the characters of tubercle.   The spleen may increase from a slight
enlargement to three, four, five, and six times its  normal  size.
   Tumors occurring after suppression of the above-mentioned  hemor-
rhages do not generally become a subject of anatomical research until
they have  attained a very considerable size.  They are  most probably 
OF  THE  SPLEEN.
135
the result of repeated typical (typische) hyperaemiae, and would be found
at their commencement to be of slight consistency, and of a red color.
A coagulable fibrinous deposit, however, takes place,  and the tumor,
therefore, in proportion to the amount of  coagulation, becomes hard,
elastic, and indurated, the parenchyma is reddish-brown, of the color  of
fresh muscle, and presents on section a fleshy (sarcomatous) appearance ;
by degrees' the coloring matter is absorbed, the  organ then presents a
pale red,  yellowish, or reddish-white appearance, and resembles fibrine
that has been washed.  During the hyperaemiae the fibrous  trabecule also
increase in quantity and toughness, so that the tumor becomes more re-
sistant ; the  fibro-serous capsule is also rendered more opaque, and is
thickened; it is invested with a cellular pseudo-membrane,  resulting from  "
peritoneal inflammation, and is thus attached to the abdominal parietes.
The deposit gradually increases to such an extent as to induce a compres-
sion of the vascular portion of the spleen, and to render it impermeable to
injections ; for the same reason, the tumor gradually becomes paler, and a
vicarious development of the vessels at the fundus of the stomach ensues.
   The third variety of  splenic  tumors bears a general  affinity to those
accompanying the above-named cachexiae, but the deposit  that occurs in
them and is substituted for the parenchyma  of the organ much resembles
bacon in consistency and appearance;  the organ on section offers a very
smooth surface, a dull, lardaceous (speckig, baconny),  waxy gloss, and
its superficial layer appears partially transparent;  the spleen is hard, but
breaks with a peculiar fracture; it presents a color varying from dark
purple to pale  red, and the blood  contained in  the vessels is pale and
serous ; this  variety of splenic tumor is often coincident with the  analo-
gous lardaceous infiltration of the liver (vide p. 100): it may, however,
occur in an isolated form, or complicated with a similar affection of the
kidneys (a variety of Bright's  disease).  Like the other  varieties, this
tumor may attain  an extreme size, and dropsy, and  especially ascites,
are common results.
   b. We  have lastly to advert to  the fact  that  many cases of swelled
spleen depend  upon the formation of  certain corpuscles, in addition  to
the coexisting hyperaemia.   These small bodies are quite distinct from
the  Malpighian corpuscles, found in the spleens of some graminivora;
they are minute grayish-red, or grayish-white, opaque, soft, deliquescent,
vesicular substances, of the size of a millet-seed, which occupy the paren-
chyma of the spleen.   They accompany a morbid development of the ab-
dominal  lymphatics, and especially of the  follicular apparatus of the
intestinal mucous membrane, with turgescence of the mesenteric glands,
occurring in  those  affections of children and young subjects, which we
have spoken  of at page 61; they are also found in typhous affections of
these organs, and of the spleen, and indicate a predominance and quali-
tative derangement of  the  lymphatic  system.   They are consequently
also found complicated  Avith acute and chronic  tumors of the spleen,
and are not to be confounded with acute tuberculosis of that organ.
   The consistency of the spleen, as may be  gathered from the above re-
marks,  depends almost  entirely upon the state  of aggregation of the
parenchyma, or of the morbid product which has replaced the latter.
The condition of the fibrous tissue also influences  it to a certain extent, 
136
ABNORMAL CONDITIONS
but it varies much even within the  limits of its physiological condition.
The tAVO extremes constitute softening and induration of the spleen, which
we have already examined in their strict sense.
  In very rare cases, the black  softening of  the tissues of the fundus
ventriculi, is  accompanied  by a similar affection of  the splenic tissue,
which is converted into  a  black, carbonaceous, tarry,  semi-fluid mass,
originating in the vascular system.
  3. Inflammation of the  Spleen.—The very important conclusions to
be derived  from pathological anatomy in reference to  inflammation of
this organ,  and with regard to its influence upon sanguification, will be
self-eATident.
  We cannot  doubt that the pulpy substance  of the spleen may be the
original seat of inflammatory action ; the fact  has not,^ however, been as
yet anatomically demonstrated; in the same manner it is not improbable,
though by no means proved, that many acute and chronic tumors of the
spleen may be the product of inflammation.
  The variety of  inflammation for  which pathological  anatomy affords
an explanation is, to name it from its seat, phlebitis, i. e., an inflamma-
tion of the numerous anastomosing  and tortuous venous canals of the
spleen.   In fact, we have only to apply the doctrines promulgated with
regard to inflammation of a vein to a venous ganglion, in order to obtain
a correct picture of inflammation of the spleen; that which elsewhere
takes place in a simple vascular tube is here found in a complicated
venous apparatus.
  This inflammation of the spleen occurs as a primary or as a secondary
affection.   Whilst the former is as rare  as spontaneous  primary inflam-
mation of a vein,  the latter is as frequent as secondary phlebitis.
  Primary inflammation of the spleen, if not  early combated, or unless
ending in resolution, gives rise to an exudation of laudable pus or fibrine.
In either case the circulating fluid may become infected, and coagulation
be produced in the most various  regions of the vascular, and especially
in the capillary system.  This is an explanation of so-called metastases.
However, this  is unusual in  the case of fibrinous exudation, as the in-
flamed vessels are closed by the  coagula, causing obliteration and subse-
quent conversion of the inflamed part of the spleen into a fibro-cellular
callus, which may even ossify.
   In the case of  purulent exudation, inflammation of the spleen  passes
into suppuration, and abscesses form.   In  a favorable case, the  abscess
may be  circumscribed by adhesive inflammation, and, being enclosed in
a sac formed by obliterated parenchyma, which has been converted into
fibrous tissue, may be borne for a long period);  a partial absorption of the
pus may take place, and the remainder  becoming inspissated be reduced
to a calcareous greasy pulp, or  even to a hard concretion.  The more
common case is that the parietes of the abscess also put  on inflammatory
action, and suppurate, in consequence of which the abscess generally en-
larges very rapidly, with symptoms of violent and universal reaction in
the shape of hectic fever. We then have a case of florid (floride) splenic
phthisis.
   If the inflammation extends to the sheath of the spleen, inflammation
of the splenic and neighboring peritoneal surface ensues ;  an occurrence
which is analogous  to the communication of  disease from an inflamed 
OF  THE  SPLEEN.
137
vessel to the tissues in  its vicinity: the  inflammation  is not, however,
apt to spread far.
  The splenic abscess not unfrequently discharges,
  Firstly, Into the abdominal cavity;  the pus is then often enclosed by
the product of circumscribed peritonitis, which causes the formation of a
sac, bounded by the external wall of the  abdomen and the diaphragm,
the fundus ventriculi, the colon, and its mesentery; the  entire spleen is
thus occasionally destroyed by suppuration.
  Secondly,  Into the left thoracic cavity, after  suppurative destruction
of the diaphragm, or,
  Thirdly, Into the cavity of the transverse colon, and into the stomach.
  Secondary inflammation of the spleen is of frequent occurrence in all
cases in which the  blood is poisoned by the absorption of an  inflamma-
tory product, or has become affected in an analogous way spontaneously,
a fact which  indicates the delicate reaction of the spleen to a morbid con-
dition of the blood.  We then see  the formation of inflammatory spots,
which  are in every  way remarkable.    They are well defined; they
always occupy the peripheral portion  of  the  organ, and generally pre-
sent a cuneiform shape, the base being  at the surface, the apex being
directed towards the interior; there are often two, three, four, and more
of these foci present at the same time ; they vary in size from that of  a
pea, to that of a hen's  egg, and in rare cases involve an entire  third of
the viscus.
   The substance of the spleen appears considerably darker at these spots,
from the commencement, and also denser and more resistant; it subse-
quently assumes a reddish-brown color, and its density also increases, so
that the affection may be at once identified, even externally; its limits
are now well defined,  and reactive inflammation is set  up in the adjoining
tissue.  The  process may terminate in  various ways:  in favorable cases,
especially when a benignant fibrinous  exudation has been absorbed into
the blood, as frequently occurs in inflammation of the internal mem-
brane of the bloodvessels, and particularly of the endocardium,  the dis-
eased tissue is converted into a cellulo-fibrous callus, which contracts and
causes a cicatrix at the surface, by drawing  the sheath of the spleen in-
wards.  The more common case is that pus or ichorous matter is absorbed,
and that the  inflamed portion is converted into a puriform, creamy mass,
or into a sanious,  greenish, greenish-brown, or  chocolate-colored pulp;
in the latter  instance, the conversion is often effected with very violent
symptoms, without  previous induction of the paleness above described.
   The entire process is a detailed repetition of that occurring in secondary
phlebitis, and is nothing more than the  metamorphosis of an  infected
coagulum within the channels of a vascular ganglion.
   When the disease  affects  the peripheral portions of  the  organ, peri-
tonitis  frequently  supervenes,  and an eschar  having^ formed   in  the
sero-fibrous sheath, a discharge into the  abdominal cavity is not rarely
effected.
   This secondary inflammation of the spleen is a very  frequent compli-
cation of inflammation of the internal  vascular coat, and particularly of
endocarditis.   Of all organs that are affected in a similar manner, by the
absorption of a product of inflammation into  the blood,  the spleen is the 
138      ABNORMAL  CONDITIONS  OF  THE  SPLEEN.

most liable to be attacked.  When occurring as a result of spontaneous
disorganization of the blood, it is particularly important in complication
with croup,  as also with exudative processes on mucous and serous mem-
branes, particularly  with pneumonia, and, lastly, with  the analogous
process of tubercular disease.
  4.  Gangrene of the  Spleen.—Gangrene is as rare^ an  occurrence in
the spleen as in the liver; Ave have had an opportunity of observing it
once in a chronic tumor of  the spleen, affecting the organ to a conside-
rable extent.
  5. Adventitious groivths.   a. Anomalous, fibrous,  and fibro-cartila-
ginous tissue.—This tissue occurs—
  a. Very often upon the surface of the organ underneath its peritoneal
sheath, in the shape of smooth and  level, or tuberculated plates, of vary-
ing thickness and size.  It occurs in this shape at  advanced  periods of
life, as a result of the congestion to which  the parenchyma and the in-
vestment of the organ have been exposed.  It is not very unusual to find
these laminae of such an extent as  to  invest the entire convexity of the
spleen, and to present a thickness of several (two, three, and five) lines.
  /?. It occurs very rarely in the shape of fibroid  tumors of  the paren-
chyma of the spleen.
  b. Anomalous osseous growths.—We find them occurring—
  a. As ossification of the fibroid laminae just described, of the same
extent and thickness as the latter;  they are rarely found except in very
old people;
  (3. As cretified fibrine in the cellulo-fibrous callus, subsequent to  pri-
mary and secondary inflammation of the spleen ;
  y. As round  unattached  concretions, or phlebolithes, in the venous
channels of the spleen.
  c. Formation of cysts.—-Encysted tumors of the spleen are very re-
markable, and as unusual as cancer, a fact which is interesting on account
of the contrast with the frequency of tubercle.   The  acephalocyst is either
found in the spleen alone, or concurrently with one  in the liver; it rarely
attains  the  size it reaches in the latter organ, but is  otherwise not dis-
tinguished by any peculiarity.  Cysts  with other contents are still less
frequent.
  d.  Tubercle.—Tubercular disease affects the spleen only less frequently
than the  lungs and  the lymphatic glands.  It always characterizes an
advanced  stage of tuberculosis, which  had previously only appeared as
chronic disease in some  other organ, as the lungs, the brain, or the lym-
phatic glands, or had merely existed  in a latent form, and is now con-
verted into acute general tuberculosis.  Splenic tubercle is consequently
always complicated with tubercle in the most various organs and very
frequently with universal tubercular deposit.
  Tubercle of the spleen, when acute, commonly appears in the shape of
numerous densely-sown granulations of the  size of a pin's head or millet-
seed, resembling gray transparent vesicles, or of an opaque white color •
or as yellow cheesy masses,  varying in size from a millet-seed to a pea.
When chronic, it presents the shape of crude, originally gray  granula-
tions of the size of a millet- or hemp-seed, which subsequently are con-
verted into a cheesy substance. 
            ABNORMITIES  OF  THE  PANCREAS,  ETC.        139

   The parenchyma of the spleen is the seat of tubercle ; we not unfre-
quently find a small central cavity within the tubercle, and the latter is
occasionally surrounded by a cyst or capsule of fibro-lardaceous texture,
a fact which demands special investigations for its elucidation.
   For the same reasons  that  apply to hepatic tubercle, tubercle of the
spleen scarcely ever passes beyond the stage of commencing ramollisse-
ment.
   The spleen appears SAYollen in proportion to the quantity, and also to
the size of the  tubercles:  in acute tuberculosis its  turgescence  and the
relaxation of its parenchyma strongly resemble the typhous condition.
   e.  Cancer.—Cancer occurs very rarely; Ave have as yet only met with
the medullary variety in combination with cancer of other  organs, espe-
cially of the liver and the lumbar glands.  The structure of the spleen
appears to afford a satisfactory explanation of the fact, that cancer oc-
curring in  it is frequently invested by a fibrous sheath, within which it
passes into a state of ichorous solution.   The sheath  is formed by the
displaced fibrous tissue of  the spleen, which, in the case of the adventi-
tious growth attaining a considerable size, is strengthened by the fibrous
investment of the spleen.

     SECT.  IV.—ABNORMITIES OF THE  PANCREAS,  AND THE OTHER
                          SALIVARY GLANDS.

   We shall first  examine  the abnormities affecting the parenchyma of
the  above-named glands, and  then proceed to examine  those of their
efferent ducts, and of their contents.  We may observe, generally, that
these organs are not very  liable to become diseased.

   § 1.  Abnormities of the Pancreas and the Salivary Glands.—1. Be-
fect and excess of formation.—Absence of the pancreas and the salivary
glands is only observed in  very imperfect monstrosities; salivary glands
sometimes present an arrest at a very low stage  of development, inas-
much as they may be blended with one another and with the thymus and
thyroid glands, so as to form one mass.  Excess of development occurs
very rarely in the shape of a double pancreas, or of an extravagant de-
velopment of accessory appendages.
   2. Beviation in size.—Enlargement  of the above-named glands,  in
consequence of hypertrophy, is altogether unusual; but when it  does
occur it affects not so much  the acini themselves, as the interstitial cellular
tissue.  The gland therefore  almost invariably becomes more compact
and drier,  and then presents simple non-malignant  induration.
   A diminution of the pancreas is the result of atrophy.   Occasionally,
and particularly  at an advanced age, this takes  place  spontaneously, ox
it may be induced, secondarily, by other anomalies, such  as  chronic in-
flammation and adipose infiltration, or the deposition of calcareous matter
in the efferent ducts.  The atrophic state is accompanied by variations
of consistency, the organ  sometimes presenting coriaceous tenacity, at
others a lax and pultaceous condition.
   3. Beviations of consistency.—We meet with the most various degrees
of consistency in the pancreas.  The two extremes only come Avithin the 
140
ABNORMITIES OF
range of pathology; they are on the one hand extreme cartilaginous dry-
ness of the tissue, and induration which is  generally coupled with en-
largement ; on the other extreme softening, relaxation, and succulence of
the tissue.
  4. Biseases of the tissues,   a.  Inflammation.—Inflammation  of the
salivary glands is either acute  or chronic, and it is  either primary or
secondary ; in the latter case it is  metastatic.  Inflammation of the pan-
creas, at all events in the acute  form, is extremely rare : this is not the
case with the other salivary glands, especially with the parotis; here the
inflammation is very often primary, and still  more frequently metastatic.
  The acute form is characterized in the following manner: in the first
instance there is tumefaction of the gland, reddening, congestion, relaxa-
tion, and succulence, i. e. infiltration of the interstitial cellular tissue;
in the progress and  in the  higher stage of the disease, a sarcomatous
condensation of the  cellular tissue follows  as  a consequence of  plastic
exudation into its areolae ; the congestion and reddening attack the acini,
which appear to be fused with the former, and the entire gland is enlarged
and  indurated.   Unless the  inflammation  pass  into  resolution,  small
punctiform abscesses result, which enlarge, become more numerous and
coalesce; the gland, and particularly the cellular tissue, is  now found
uniformly infiltrated with yellow pus, which exudes from  it as from a
sponge, whilst  the acini appear as small,  red, lax, friable corpuscles,
which fuse at a later period; or  suppuration  is established at  distinct
spots so as to form an abscess, which may discharge itself in various di-
rections, subsequent to the destruction of the adjacent tissues.
  Chronic inflammation induces condensation, induration of the  cellular
tissue,  obliteration of the  acini, and  either permanent enlargement or
subsequent atrophy  of the gland.
  The metastatic forms of inflammation not unfrequently pass rapidly
from the stage  of hyperaemia with livid redness, into sanious ulceration,
Avith sudden disappearance of the  turgor.
  b. Adventitious growths.—The salivary glands are not very subject to
the formation of morbid growths : tubercle is never discovered in  them,
and  carcinoma rarely attacks  them primarily.  We  find the pancreas
liable to—
  a. Excessive accumulation of fat, which may terminate in a conversion
of the entire organ  into one mass of fat.   This affection rarely occurs
without a coincident accumulation of fat in the abdomen.  The disease
proceeds from without inwards, and in very  obese persons a direct com-
munication may be traced between the  surrounding fat and the pancreas;
the cellular tissue gradually absorbing  the lax greasy fat, the acini, which
are of a dirty yellow color, being reduced  and gradually disappearing.
When  the disease has attained its  extreme limits, a mere pultaceous strip
of fat retaining the general outlines of the gland is found in its place * only
scattered remains of the acini are discoverable, and in  the delicate and
thinned duct there is a whey-like fatty fluid.  The disease occurs  fre-
quently in drunkards, associated  with  fatty liver and the  formation of
biliary calculi.
  ,?. Cysts.—Serous cysts  are  occasionally formed  in the pancreas  as 
THE  PANCREAS, ETC.
141
well as in other salivary glands.   They are to be carefully distinguished
from dilatations of the ducts  and their  terminations, which put on a
similar appearance.
  y. Fibrous tissue, cartilaginous and osseous growths.   Tumors  of this
description occur but very rarely in the parotid.
  8. Carcinoma.—Carcinomatous disease occurs, in the pancreas and sali-
vary glands, and especially in the parotid, in the shape of scirrhus and
medullary cancer.  In  the parotid it sometimes  appears as a primary
disease; in the pancreas we have only found it, and even then exclusively
at its duodenal end, as a complication of extensive carcinoma of numerous
other organs.  The secondary affection of the salivary glands  by an ex-
tension of the disease from adjoining organs,  and in the case of the pan-
creas especially, by an extension  from the  scirrhous pylorus, is very
common.   Cancer  appears in  the shape of infiltration of the interstitial
cellular tissue of the gland or of nodes.  Dr. Berg has,  during his resi-
dence in Vienna, discovered carcinomatous induration of the entire pan-
creas in a new-born child.

  § 2. Abnormities of the different Bucts and of their Contents.—Next
to salivary fistula subsequent upon injuries and ulcerative destruction of
the tissues, which occurs chiefly at the  ductus stenonianus, but which we
have also seen in the shape of pancreatic  fistula (see p.  39) discharging
by  a perforating ulcer of the stomach, we find dilatation of the excretory
ducts and of the ductuli salivales to be the chief and most frequent affec-
tion that  has to be noticed under this head.
  Dilatation depends mainly upon retention and accumulation of  the se-
cretion, and may either affect the entire duct  or one portion uniformly, or
small detached points, so as to form saccular or varicose dilatations ;  in
the  latter case, again, the duct may present  single fusiform or vesicular
dilatations at intervals, or numerous closely-set  expansions, which are
partially  separated from one  another  by valvular folds formed  by the
coats of the duct.  The coats may be  either considerably thickened  or
considerably attenuated.
  The cause is generally to be found in some mechanical impediment, such
as compression and complete obliteration of the duct external or internal
to  the  gland by morbid growths of various descriptions.   In the pan-
creatic duct it may be induced by gall-stones occupying the orifice of the
ductus choledochus, by a sudden curve or  angle of the duct brought on
by  cancerous induration and  shrivelling of the normal tissue, with change
of position, such as we often observe in the pancreatic duct near the head
of the pancreas. It may be induced by tumefaction of the internal mem-
brane, by a mucous plug, and especially by calcareous concretions (sali-
vary calculi).  In rare  cases the dilatation of the pancreatic duct  is, like
that of the bronchi, brought on by induration and atrophy of the  gland.
In  morbid softening of the gland, and especially in the adipose meta-
morphosis, the duct is deprived of its contractility, and dilatation  Arith a
marked attenuation and  relaxation of its parietes ensue ; lastly,  dilata-
tions of  the duct may take place without any mechanical obstruction,  in
consequence of scirrhoid disease of its duodenal  end; the duct in this
case fuses with the scirrhous portion  of the gland ; it  is thus  fixed, the 
142        ABNORMITIES  OF THE  PANCREAS,  ETC.

scirrhus  involves its  tissue, whereby its vital  contractility becomes im-
paired, and the secretion is allowed to stagnate in its cavity.
   The dilatations of the pancreatic duct enlarge to the size of a goose's
or swan's quill; the saccular expansions may reach  the size of a hazelnut
or pigeon's egg.  In  Wharton's duct the dilatation occurs in the shape
of a fluctuating tumor, and is known as ranula.  Dilatation of the ductuli
and their terminations sometimes puts on the shape of serous cysts.
   The contents  of  the salivary ducts, i. e.  the saliva of the mouth  and
stomach, occasionally offer rather remarkable  anomalies in reference to
quantity, color, consistency, and probably, as indicated by the taste, and
especially by its acid or alkaline reaction, in reference to chemical con-
stitution.   Not unfrequently calculous concretions, the so-called salivary
calculi, are generated in the saliva, and  this is more especially the case
in the ducts of the sublingual gland and the pancreas.   They  are white,
friable, and either round, oblong, cylindrical, or obovoid ; in size varying
from that of a millet-seed or a pea, to even that of a hazelnut; they are
either solitary, or if small, frequently very numerous (twenty and more);
and they are composed of phosphate and carbonate of lime, held together
by animal matter.   These calculi give rise to obturation of the  ducts, and
consequent accumulation of the secretion and dilatation.
   At times, blood, pus, cancerous sanies, is found in the salivary ducts;
bile is not unfrequently discovered in the pancreatic duct; in one case of
migration  of lumbrici into  the  biliary vessels, two Avere found to have
crept into the latter. 
           PART II.




ABNORMITIES OF THE URINARY ORGANS. 
 
PAKT  II.
          ABNORMITIES  OF  THE URINARY ORGANS.

  Under this head we comprise the morbid anatomy of the kidneys and
the efferent apparatus, viz. the calices, the bladder, and the urethra ; the
two are of course very intimately related to one  another.   The abnor-
mities of the suprarenal capsules will be considered in an appendix.


             SECTION I.—ABNORMITIES OF THE KIDNEYS.

   § 1. Befect and Excess of Formation.—The urinary apparatus is very
rarely entirely deficient; it  is  generally found even in  very imperfect
monstrosities.   One kidney  is frequently absent, or  individual portions
of the system  are, as we shall have occasion to sec, more or less imper-
fectly developed.
   When one kidney only is present, it is important to distinguish between
the unsymmetrical and the  solitary kidney.  The former is represented
by a right or left kidney, which is normal in regard to position and con-
formation, and occasionally rather enlarged, its fellow being deficient.  The
solitary kidney is the result  of a fusion of the two organs, and therefore
offers the characters peculiar to this arrangement in a greater or  less
degree.  The  lowest degree  of  fusion is seen in the horseshoe kidney
(ren unguliformis); the two  kidneys are united at their inferior portions
by a flat, riband-like, or rounded bridge of tissue, which crosses the ver-
tebral column.  In the higher degrees the two lateral portions approach
one another more and more, until they reach the highest degree, in which
a single disk-like kidney, lying in the median  line and provided with a
double or a single calyx, represents complete fusion.  The more intimate
this union is, the more the hilus of the kidneys is directed forwards, so
that whereas,  in the lowest  degree, it is indicated  by an evidently in-
creased development of the posterior labium of the hilus, the  hilus of the
solitary kidney occupies the anterior surface.   The more considerable the
fusion is, the more the kidneys descend along  the vertebral column,  and
the solitary kidney is commonly situated at the promontory,  or even at
the concavity  of the sacrum.   In exceptional  cases only the solitary
kidney is placed, like the unsymmetrical kidney, at the side of the verte-
bral column, on one side of the median line.
   Excess of development occurs very rarely, except in the case of biven-
tral monsters, in the shape of a  third  kidney, situated in the median line,
and generally placed at the promontory;  or in the  shape  of a single
symmetrical kidney, which is composed of two kidneys united into one.
  VOL. II.                           10 
146
ABNORMITIES  OF
   § 2. Beviations of Size.—The  kidneys are  found enlarged  or dimi-
nished in various degrees, and under various circumstances.
   1.  Enlargement is observed—
   Firstly. Occasionally in one kidney, after its fellow has been deprived
of its functions;  this is a case of hypertrophy Avhich  may be considered
as analogous to the increase of size in the unsymmetrical kidney ;
   Secondly.  As congestive turgor ;
   Thirdly. As inflammatory SAvelling ;
   Fourthly.  As a consequence of infiltration of the renal tissue induced
by or independent  of inflammation: various forms  of  Bright's  disease
belong to this subdivision;
   Fifthly, as arising from morbid growths, in Avhich case  the enlarge-
ment corresponds to their number and size ;
   Sixthly. As originating in dilatation of the pelvis and calices of the
kidneys;  the greater in this case the increase of size, the more will the
renal substance become atrophied in consequence of pressure from within.
Rayer states the  left kidney to be normally of greater weight and larger
dimensions than the one on the right side.
  Abnormal  smallness is either congenital, or the result  of atrophy.
Spontaneous  and primary atrophy occurring independent of contraction,
or complete occlusion of the artery, is very unusual, and belongs almost
exclusively to old age; secondary atrophy, resulting from and compli-
cated with disease of the tissues, is much more frequent.  In the case of
extreme dilatation of the renal pelves  and calices  atrophy and enlarge-
ment  appear  combined.
  2. Atrophy may affect the tAvo substances of the kidney uniformly;
or it  may involve the cortical  substance  only; the latter is the more
frequent case in secondary atrophy, on account of the greater proclivity
to disease in the cortical substance.   The tissue  is rendered pale, or  it
may be distinguished by its darker color, and the vessels are often found
varicose.  We  very often find an unusual amount of  fat accumulated
round the atrophic kidney.
  We shall have occasion to enter more fully into  the subject of secon-
dary atrophy, at a future period.

  § 3. Beviations of Form.—Besides the anomalous  forms  of the kid-
neys,  resulting from fusion of the two organs,  which Ave have  already
described, we may point to the lobulated kidney as an interesting con-
formation. ^ It occurs as an arrest of development in the foetal state,
or if acquired, as atrophy of the cortical substance,  accompanied by
dilatation of the calices.   There are other congenital malformations of the
kidneys, which are  of less importance,  as, for instance, the elongated
kidney, which appertains to the foetal state, the round,  prismatic  trian-
gular, cylindrical kidneys, the kidneys Avith  a  transverse furrow' (sepa-
ration into an upper and lower  half);  and also various acquired mal-
formations, which are caused by external pressure, by partial  loss of
substance, and atrophy.

  § 4. Beviations of Position.—Here too Ave  must first point to an
anomaly resulting from the various degrees of  fusion of the two organs 
THE  KIDNEYS.
147
i. e. the descent of the kidneys to a  lower part of the abdomen.  This
may, however, occur independently of the malformation  alluded to, and
Ave sometimes find one, sometimes both kidneys, as low down as the brim
of the pelvis, or even as the holloAV  of the sacrum.   The anomalies in
the origin of the renal  vessels which correspond to the original devi-
ation  of position deserve attention, as well as the increase in their num-
ber and the diminution  of the  ureter in proportion  to the descent of
the kidney.
  The kidneys,  and especially the right  one, may be  depressed  by an
enlarged liver, and the consequence  is, that the hilus of the former is
turned upwards, as the upper portion of  the kidney is necessarily most
depressed.
  We have lastly to allude to the occasional movability of the kidneys,
which is owing to insufficient fixation by means of  the  adipose  fascia,
and apparently also to an  elongation of the  vessels; Ave sometimes find
that the kidneys may be  moved from  one  to tAVO inches along the spinal
column.

  § 5. Beviations of Consistency.—The kidneys sometimes offer  a dimi-
nution of consistency, or relaxation, or an increase of resistancy or tough-
ness, without any apparent change  of texture.  The former occurs con-
currently with a similar  condition in other parenchymatous organs,  and
is the result of cachexia, anaemia, and marasmus, and of  defibrination of
the blood, from  excessive exudations;  the organs,  in this  case, are very
pale and friable.  Both an increase and a diminution of consistency are
much more frequent as complications  of textural alterations, and we shall
examine them more in detail under this head.   Genuine  softening of the
entire kidney, or of a portion of the organ, in the  shape of spots of vari-
ous sizes, of a dirty broAvn, chocolate-colored, rusty pulp, is a  very  rare
occurrence.

  § 6. Solution of Continuity.—This is produced not only by cutting in-
truments, but may occur in the shape of  rupture, from concussion, or in
consequence  of  falls or  blows, received in the  region of the kidneys.
After a fall from a considerable height, rupture of the kidneys is very fre-
quently complicated with laceration of other abdominal viscera.  It gives-
rise to hemorrhage, inflammation, and suppuration  ; the latter terminates
in the manner that we shall have occasion to delineate when speaking of
renal abscess.  Concurrent injury of the calices  and  of the pelvis  of  the
kidney, causes extravasation of urine  into and beyond the adipose cover-
ing of the kidneys: if the peritoneum has also suffered, a fatal termina-
tion ensues rapidly; if not, a permanent or temporary cure, with  a resi-
duary fistula, may follow.

  § 7. Biseases of the Tissues.   1. Hyperaemia, apoplexy, anaemia.—
Hyperaemia of the  kidneys not unfrequently occurs  in the active form
accompanying an exaltation of the renal functions ; or as passive conges-
tion in consequence of general marasmus,  and especially in consequence
of paralysis of the spinal and ganglionic nerves,  such as  we find  in  the
torpid condition of the sympathetic in the insane,  connected with abdo- 
148
ABNORMITIES  OF
minal plethora and congestion, and in paraplegic cases; it also occurs in
the mechanical  form as a consequence  of impeded circulation in con-
nection with hyperaemia of other organs.  The effects, are swelling of
the organ (congestive turgor)  and  increase of size,  greater depth of
color of the tissues, increased density and resistancy, and  loose attach-
ment of the fascia propria.  In children  the tubular portion is frequently
the chief seat of hyperaemia.  When it has reached a high degree, it is
apt to  give rise to spontaneous hemorrhage (renal apoplexy), which, both
in children and adults, has its  main seat in the  pyramids. ^ We  then
find in the place  of the pyramids, a spot of various dimensions, which
has pushed  aside a proportionate amount of parenchyma,  and contains
besides coagulated dark blood, the broken-up remains of the tubular sub-
stance.  A cure undoubtedly ensues occasionally ; the effusion gradually
loses its color, and assumes a rusty and a  yelloAv tint; it is then absorbed,
and the calyx becoming obliterated, a fibro-cellular cicatrix closes up the
cavity.   Minute hemorrhagic spots, in the shape  of  ecchymoses of the
tissue resulting from an acute disorganization of the blood, as well as small
extravasations under the tunica albuginea, are of much more frequent
occurrence.
  Hyperaemia accompanied by increase of size (hypertrophy), is, accord-
ing to  the few cases we have  been able to examine, the only anomaly of
the kidney, demonstrable in diabetes by the pathological anatomist.
  Anaemia  of the kidneys occurs not only in connection with general
impoverishment of the blood, but it is found as a more or less character-
istic symptom, in all those  cases in which  the  renal parenchyma has
become impermeable from being infiltrated with coagulable matter, either
owing to inflammation or deficient nutrition ; this is particularly the case
in that disease which is commonly cited as the type of the class, Bright's
disease of the kidney.
  2. Inflammation.—Inflammation  of the  kidneys  is either  primary,
secondary, or metastatic; in the first case it results from injury, concus-
sion of the intestines,  cold, or specific irritation (turpentine, cantharides,
&c.) ; in the second it follows acute or chronic diseases, and it then pre-
sents  a more or  less remarkable type, corresponding to the general
dyscrasia;  in the  third  instance it arises chiefly from  inflammations of
the pelvis and calices, or from inflammations of the fascia adiposa and
adjoining organs.  The inflammation runs an acute or a chronic course;
the idiopathic variety being particularly liable to the former.
  The  cortical substance is the chief seat of the first two varieties as of
textural alterations generally; when the  inflammation commences at the
pelves  of the kidneys, the tubular substance is naturally implicated also.
In the  former case we often find one or  both kidneys, either simultane-
ously   or  in rapid succession  attacked  throughout  their  substance *
whereas the latter commences in spots from which it extends through the
renal tissue.
  The following are the anatomical  characters of  acute inflammation of
the kidneys, modified of course by the degree  and the acuteness of the
affection.
  Hyperaemic tumefaction and redness  of the organ are followed by
a uniform discoloration  of the parenchyma  which appears  of a dirty 
THE  KIDNEYS.
149
brown or purple  color, and filled with a dark  sanguinolent fluid;  it is
either turgid and resistant, or collapsed, flabby, and very friable; or it
may be turgid and friable, and the discoloration less uniformly grayish-
red, or dirty white, accompanied by infiltration of a denser, coagulable,
fibrinous substance, the texture is  granular, the surface scattered over
with an  injected, asteroid, and  polyhedral vascular network,  and  the
fractured surfaces  or sections  made  in the  direction of the  hilus, are
streaked with striated vessels.
  The general result of the infiltration is, that the organ is more or less
swollen and discolored, and that its consistency is  variously diminished.
In accordance with what has  been above remarked, we  find the cortical
substance chiefly affected; the affection is general or partial, and in the
latter case  it occupies particularly the superficial layer ; in the first in-
stance the  swollen cortical substance is found  to have forced its way into
the basis of the pyramids, betAveen the fasces of  the tubuli,  and they
consequently appear  unravelled and fimbriated.
  The process not unfrequently extends to the tubular  portion itself,  or
the latter is involved in the inflammation propagated from the pelvis.
The pyramids then appear  enlarged, swollen, pale ;  their color changed
to a dirty brown, or grayish-red, and softened or indurated according to
the nature of the inflammatory products; the  inner membrane of the
calices and pelvis is in both cases injected as  in catarrhal inflammations,
reddened and relaxed, and  filled with an opaque, flaky,  grayish,  or
yellowish-brown fluid.
  Externally we find the fascia  propria, and even the adipose covering
of the kidneys involved in the inflammatory process :  the former is easily
detached from  those  portions of the surface Avhich present the vascular
injections above spoken of, its tissue  is more  or less injected and tume-
fied ; the latter is infiltrated with serum, and softened.
  This inflammation  occasionally affects one kidney only, but very often
both are simultaneously  attacked: in the latter case,  especially, it is
liable to terminate fatally, in  consequence of paralysis of the renal func-
tion with typhoid symptoms, resulting from retention of the urea in the
blood ; this is frequently complicated Avith serous effusion into the ventri-
cles of the  brain, or into the pulmonary tissue, followed  by putrescence ;
or if the inflammation reaches a certain degree of intensity, suppuration,
or an excessive retrograde  process, or atrophy may result; or, lastly,
the affection may become chronic.
  Suppuration is not a frequent consequence.   The inflammatory  pro-
duct  which  has been infiltrated  in  detached  sections,  or  uniformly
throughout the  organ, is converted  at first  into small punctiform  or
millet-sized spots of  white, creamy, or  yellow  pus, which subsequently
coalesce into a small abscess.   In its vicinity a renewed reactive  pro-
cess is set  up, and we find  a  red injected halo, varying in  size, which
gives rise  to a similar fusible  product leading to an extension of the
abscess.  The original small abscesses are sometimes found scantily dis-
persed  through the  kidney,  at others  they  are grouped together,  at
others, again, they are thickly  sown  through  the entire kidney; they
are then characterized by the surrounding inflammatory halo, and this
renders  them  conspicuous though individually almost imperceptible. 
150
ABNORMITIES  OF
They are always incomparably more numerous in the cortical substance;
they here generally retain their rounded shape, even  whilst enlarging,
whereas  in  the tubular substance they are  converted into  elongated
striated abscesses.
   In  the manner just described, as well as by the coalition of  several
abscesses, we see an  extensive purulent accumulation brought about,
which may increase so as to occupy one-half or two-thirds, or more, of
the kidney.   Moreover, there may be  one or more of these accumula-
tions, and their existence establishes phthisis renalis.
   Renal abscess extends in the most various directions from the inflam-
mation and  suppurative fusion  spreading through the kidney,  and even
beyond its sheath;  we most frequently find  it presenting excavations or
sinuses, backwards and downwards;  it causes death by exhaustion, or if
the progress of the fusion is  stopped, the surrounding parenchyma may
become obliterated, or in the case when suppuration  has  extended be-
yond  the latter, the  fasciae of the kidney may become converted into
cartilaginous tissue, and the abscess thus be enclosed and be borne for a
long period; it may be reduced in  size, and may even heal  up, leaving a
cicatrix ; this is particularly liable to result after  an opening and a dis-
charge have been effected in a faArorable direction.
   This discharge may take place:
   Firstly, into the cavity of the renal pelvis ; the pus is then discharged
by the urinary passages;
   Secondly, into the peritoneal cavity ;
   Thirdly, externally in the lumbar  region, by means of sinuses of
various dimensions ;
   Fourthly, after previous agglutination of the intestine to the walls of
the abscess and perforation, into the caAdty of the former; it is  evident
that the  ascending  and descending colon, and the sigmoid flexure, are
particularly liable to be thus involved,  and in second  order  the  duo-
denum.
   Fifthly, renal  abscess has also been  seen  to  communicate  with the
lungs after perforation of the diaphragm; its contents are then expecto-
rated in the shape of urinous-purulent sputa.
   These discharges may sometimes  take place  in various  directions at
once; a combination of the discharge  into the urinary passages  with
elimination  of urine  by a false passage—renal fistula, is of  especial
interest.
   Termination in  gangrene or gangrenous suppuration  is extremely
rare ; it is more usual to find acute inflammation passing into the  chronic
form.
   Chronic inflammation of the kidney either commences in that form
or is the result of acute inflammation, or, as is most frequently the  case
it is the consequence of inflammation of the urinary passages, and espe-
cially of the calculous variety.   It is distinguished from acute inflamma-
tion by a loAver intensity of the symptoms, by its smaller extent  and by
the variety of stages presented by the coexisting and consecutive inflam-
matory spots.  Chronic  inflammation  also not unfrequently terminates
in suppuration, which is particularly the case Avith the variety originating
in calculous irritation of the renal pelvis;  it also frequently terminates 
THE  KIDNEYS.
151
in induration  and obliteration of the parenchyma, or induces, atrophy of
the kidney.
   In the former case the coagulable portion of the infiltrated and accu-
mulated product of inflammation is converted into a Avhitish, fibro-larda-
ceous,  cartilaginous callus, in Avhich the renal parenchyma has entirely
disappeared.  The kidney is often found increased in bulk, and appears
altered in shape,  from the irregular accumulation of the product,  giving
rise to various tuberculated projections.  This tissue  may here, as else-
where,  subsequently  become shrivelled and condensed, and  is also,  in
a  few  cases,  the  seat of bone-earth  deposit, osseous transformation,
ossification.
   Chronic inflammation is, like  the  acute form, frequently followed by
atrophy of the kidney ; inasmuch as not only its product but the original
tissues  themselves become  absorbed.   This secondary atrophy attacks
either  the entire  kidney or sections of the  organ, and the consequence
is, accordingly, a uniform reduction of its size, or a partial contraction,
which gives the kidney a shrivelled and uneven, lobulated surface.   The
contraction sometimes adArances to such a degree, that the kidney appears
reduced to the size of a hen's or even a  pigeon's egg, it is surrounded
by the  tunica albuginea, that has become  thickened by the inflamma-
tory deposit, and by  contraction, and forms a callous sheath of several
lines in thickness ;  on closer examination Ave find the cortical substance
reduced to a mere vestige ;  the pyramids are diminished to a size  corre-
sponding  to  the dimensions  of the  organ ; the tissue generally is of a
pale-red, or here and there of a slate-gray  color,  denser, tough,  and
fibro-cellular; occasionally, however, it is unusually dark-red, vascular,
and  congested, and all the vessels dilated.   The calices and pelves are
uniformly enlarged, the ureters contracted,  their parietes shrivelled and
thickened, and here  and there  approaching to obliteration, or actually
obliterated.
   Inflammation of the kidneys,  with its consequences, has occasionally
been discovered in new-born infants ; but its frequency and importance
are much more considerable at  maturity and at the advanced periods
of life.
   3. Bright's Bisease  of the Kidney.—This  affection of the kidneys,
which has been named after its discoverer, Bright, and has of late been
extensively investigated, is of extreme importance.   It has been termed
granular  degeneration, by  Christison, and  nephrite  albumineuse,  by
Rayer.   We  treat  of it in  connection with inflammatory  affections of
the organ, for reasons which will appear in the sequel.
   It is generally a chronic disease;  however  there are numerous cases
that incline to an acute course,  and some equal, or even  exceed, acute
inflammation in rapidity.
   It assumes very different  forms, which have reference  either  to the
degree and rapidity of  the disease, or to its stage of development; the
former  bear  a close  relation, first, to  the amount of local reaction in
the renal  tissue, and,  secondly, to the dyscrasic state of the blood.  We
shall commence by describing the various phases Avhich the disease pre-
sents as distinct forms; Ave shall then, examine its  complications, their
course,  stages, degrees, and transitions, and lastly, arrive  at a general
analysis of the disease. 
152
ABNORMITIES OF
  The cortical substance is that which is primarily and chiefly affected;
in the course of the disease, however, the tubular substance also becomes
involved in the manner which will be immediately delineated.
  First form.—The kidney appears enlarged, swollen, heavier ; the cor-
tical tissue is almost uniformly infiltrated with dirty brownish-red, turbid
fluid, and the bloodvessels, with the tissue immediately surrounding them,
are delineated on this background in the shape of spots, or streaks of a
darker red.  Other red spots may be visible, which are owing to extra-
vasations of blood  into the tissue,—ecchymoses.   The pyramids, how-
eArer, present a similar though darker discoloration, with dull-red striae.
The entire parenchyma, but more especially the  cortical substance, is
peculiarly pulpy  and friable, and the surface, presented by section or
fracture, yields a reddish-brown, limpid, delicately flocculent and opaque,
sanguinolent and slightly viscid fluid.  The organ generally is charac-
terized  by a turgid though flabby state.   The fascia  propria, from the
injected state of  its vessels, but more from  the exudation of blood into
its  tissue, is of a dirty red  color, and is  easily detached;  the mucous
membrane of the calices and pelvis is similarly reddened and tumefied ;
and their cavity contains a thin, muco-sanguinolent, turbid, urinous fluid.
  Second form.—Besides the increase in  size and weight found in the
first variety, the cortical substance presents an infiltration of  a grayish
or grayish-red, or yelloAv, viscid, and turbid fluid,  Avhich pervades it uni-
formly or in diffused spots;  the color of the tissue corresponds, and  if
more carefully examined, an indistinct, dotted, or linear arrangement is
perceived.   At the same time, small  punctiform or striated ecchymoses
are found, which  are the more conspicuous the paler the color of the in-
filtrated tissue.   The tissue frequently presents the infiltrated and pallid
appearance in some parts, whilst the hyperaemia and ecchymoses predo-
minate  in  others;  this constitutes the combination of partial anaemia
and hyperaemia, alluded to by authors as  a special variety.   The organ
appears of diminished firmness, but this character is less marked here
than in the first form.   The renal fascia observes the same bearing, the
mucous membrane of the pelvis  and calices of the kidney is of a roseate
hue, and tumefied ; and the latter contain  a  flocculent, turbid, yellowish
or reddish-white fluid.
  Third form. — There  is  considerable enlargement  and  increase  in
weight; the  cortical substance  is  completely anaemic; and only  a few
solitary dilated vessels, bearing an asteroid, convoluted, or  striated ap-
pearance, are seen in  it.  The  cortical portion presents an increase  in
diameter of from five  to nine lines;  its surface is smooth and slightly
glossy; it is tense, friable, and  infiltrated with a  large  quantity  of
opaque, milky-white, or yellowish fluid.  The superficial layer more par-
ticularly,  but also the deeper-seated parts, are found  to be  made  up of
Avhite  or  yellowish-Avhite, loose, tense granules (Bright's granulations),
of the size of a poppy-seed, or a pin's  head ; in the neighborhood of the
pyramids these granulations assume a linear appearance.
   The  increase of the cortical substance either  extends to the base of
the pyramids only, or  affects those portions  also that dip down between
the latter; by this means the pyramids, and more  particularly their
apices, become compressed.  The pyramids  are of a pale-red color and 
THE  KIDNEYS.
153
from the granular cortical substance forcing its way between the tubuli
and separating them, the basis of the pyramids presents a frayed or un-
ravelled appearance, resembling  a plume with dependent feathers, or a
sheaf of wheat.
  The renal fascia is easily detached; its tissue is swollen and opaque,
the mucous membrane  of the calices and  pelvis of  the kidney is red-
dened, and there is a milky, turbid, viscid fluid in their cavities.
  Fourth form.—The increase in size and weight is very considerable,
and the consistency of the tissues is much diminished; the cortical sub-
stance is very tense, and here and there appears almost fluctuating ;  its
tissue  is completely anaemic and very friable, and gorged with  a large
quantity of milky-white  or yellowish juice.   The granulations  exceed
the size of millet-seeds, and equal that of hemp-seeds;  and as this  en-
largement is chiefly effected in the peripheral layer, they project from
the surface of the organ, and give it a racemose appearance.   Occa-
sionally, we find this increase of size occurring with great rapidity in
sections, and  we  then  have  an accumulation of granulations shooting
like a cauliflower from the surface, and producing  irregularities and
nodulated protuberances upon the kidney.   The granulations are very
soft,  tear and  dissolve upon  the slightest touch; the  renal  sheath is
almost unattached, the pyramids are of  a pale-red color and undefined,
and the reddened calices and  pelves contain a viscid creamy fluid.
   Fifth form.—The kidneys are enlarged or of the normal size,  or they
may  be reduced  in  size;  their surface is  granular  and racemose,  or
whilst certain portions present the nodulated and prominent appearance,
others are irregularly furrowed, indented, and cicatriform.  The  cortical
tissue is coarsely granulated, looser in  texture, very vascular and con-
gested, and the vessels are  varicose ; or else we find it, as in the  case of
a diminution  of the  organ, of pale-yellow or ashy hue, exsanguineous,
of coriaceous density, and mainly of  a fibro-cellular texture ; the inden-
tations at the  surface  here  and  there present  a similar  tissue, of a
whitish or slaty color.   We also not unfrequently see  cysts, containing
the most various substances, and varying in size from that of a  poppy-
seed  to that of a pea  or nut and more, scattered through the  cortical
structure.
   In the  former case the attachment of the  fascia propria is slight, in
the second it is more intimate : the fascia is  thickened, and the adipose
layer indurated.  The  pyramids  are small and atrophied, of increased
density, and generally of a  dirty brown  color ; the calices and pelvis  are
slightly contracted.
   Sixth form.—The organ  is  but little increased in size and weight,  the
cortical substance only presents a few undefined patches of a paler color,
and the prevailing hue is either pale red, or  it is found on closer examina-
tion to offer transitions of a pale red, a white, yellow,  or ashy color. It is
infiltrated with inspissated matter, resembling thick cream or coagulated
albumen; and not only does not present greater laxity of texture, but is
of the normal or even of increased consistency.
   The fascia propria is but slightly less adherent at these points than in
the healthy condition, and  the pyramids, Us Avell as the calices and pelvis,
are normal. 
154
ABNORMITIES OF
  Seventh form.—The increase of size is commonly trifling ; occasionally
there is partial atrophy and diminution.  There is  increase of density
and  consistency.   As in the last  variety, the cortical substance only
presents patches of a dull Avhite color, Avhich have no defined borders, and
are often very extensive; it arises from  a coagulated, albuminous, larda-
ceous-looking  substance, in which no trace  of the renal tissue remains.
We here find considerable SAvelling  of the kidney, owing to the copious
deposition of the morbid groAvth ; or the organ otherwise seems shrunk,
and presents the appearance and consistency of fatty cartilaginous tissue.
One  or more of the  pyramids occasionally undergo  a similar metamor-
phosis.  The fascia propria is agglutinated to the diseased portions of
the kidney,  and thickened; the lining membrane of the calices and pelvis
is tumefied.
  Eighth  form.—The kidney presents but a slight increase of size, or is
of normal  dimensions, but always considerably indurated.   The general
hue  is a dirty red or brownish-yellow,  and the  cortical substance pre-
sents a fatty waxy gloss, is unusually hard and  brittle, and  infiltrated
with  an albuminous, lardaceous,  and  transparent substance.   Occa-
sionally a  whitish flocculent deposit is seen in the tissue, of the shape of
fine granular dots and lines, giving to the surface and sections  a marbled
appearance.
  We have  thus enumerated the forms which, in a general point of view,
we think it proper to class under Bright's disease.  The first seven forms
undoubtedly belong to the latter, if the  totality of the symptoms, as they
appear in  the living subject, be considered:  they also occur complicated
with  one  another,  and the second, third, fourth, and fifth forms more
particularly represent Bright's disease and Christison's granular degene-
ration of the kidney.  In the latter form the disease is generally chronic,
though with an acute tendency and  occasionally exacerbations; the se-
cond, third, and fourth forms  represent progressive stages of  degrees of
the metamorphosis occurring in Bright's disease : they vary in duration,
and pass from one to the other either gradually or, as is frequently the case,
with very tumultuous symptoms.  Each of these  stages may prove fatal.
The  fifth form is the last link of the metamorphosis  ; with it the process
becomes retrograde, and the  disorganized tissue  of the viscus presents
the condition of secondary atrophy.  The different varieties are not un-
frequently complicated with one another; and we thus find the first  de-
gree (second form) attacking one  kidney, or a  section of one kidney,
whilst the other kidney, or the other sections, present the metamorphosis
of the third or fourth degree (third and fourth form).   The  peripheral
layer of the cortical substance is generally in a more advanced stao-e than
the deeper-seated layers.
  The sixth and seventh forms represent  the less  frequent  or chronic
varieties of  the disease ;  the latter (the  seventh) must be looked upon as
the terminal point of the metamorphosis, as the product of the disease is
retained in a state of condensation and organization, and  subsequently
shrivels up.   It is sometimes  complicated with the  varieties previously
spoken of.
  The first  form is extremely rare, and runs an acute course;  on  the
occurrence of powerful  exciting causes, very tumultuous symptoms  are 
THE  KIDNEYS.
155
sometimes induced, which speedily reach their climax, and  may termi-
nate fatally on the fourteenth day.
  The eighth form is invariably chronic ; we shall for the present exclude
its  consideration from the  following remarks, and advert to  it subse-
quently, for reasons that will then be apparent.
  The nature of the disease, and the scientific exposition of its charac-
teristic symptoms, have been the subject of numerous  discussions, and
we  neither venture to assume that our remarks will add great weight to
the arguments of those Avho consider it inflammatory, nor do we Avish to
anticipate further investigations and statements of depth and originality.
  We  consider the nature of Bright's disease to consist in  an inflamma-
tory process, Avhich proceeds from a stage of hyperaemia to one of stasis,
and then gives rise to  a product, which is not only remarkable by its
peculiar character, but AAThich, in well-marked cases, by its excessive accu-
mulation, causes a singular alteration in  the appearance and structure of
the kidney.  It commonly runs, as Ave  have already  stated, a chronic
course, with occasional exacerbations, but it is  sometimes acute.  In the
latter  very important cases, in  which, from the tumultuous violence of
the exudation, the product is mixed Avith a  large  amount of serum, and
is generally reddened by the coloring matter of the blood, and in which
the  characteristic milky or creamy or coagulated substance of  well-
marked Bright's disease is not formed, Ave should be obliged to consider the
condition as one of very acute simple inflammation of the kidneys,  Avere
it not  that the characteristic general symptoms and the constitution of
the urine established  it as a case of Bright's disease.
  The whitish or  ashy, milky  or creamy product, Avhich may resemble
albumen in its various degrees  of coagulation, and consists of solitary
and accumulated molecules, or of more or less globular fibrinous coagula
and pus-corpuscles (Gluge), is an albumino-fibrinous substance, Avith a
predominance of albumen ; the  amount in which it occurs is proportioned
to the  amount of granular degeneration.
  The  product  may, as in simple inflammation, be deposited at every
point of the  renal parenchyma external to the  vessels, but Ave find it
more particularly in the Malpighian bodies (glands), and subsequently
in the  urinary tubuli; the granulations of Bright's disease are  therefore
in  reality the  Malpighian corpuscles  charged  Avith  the  above-named
substance.  The more the latter accumulates, the more it interferes with
the  circulation, hence the  peculiar pallor  or  anaemic  condition of the
organ.
  The cause of the peculiar character of the product is the more obscure,
since the question is generally evaded.   As the amount of reaction that
takes place in the renal tissue does not suffice  to  explain it, we are led
to seek the cause in an  anomalous constitution of the blood, consisting in
an  excess of albumen,  which may originate in a decomposition of the
fibrino.   This  becomes the more probable, when  Ave  consider that the
most frequent exciting  cause (cold) appears peculiarly adapted to giA'e
rise rather to a change in the blood,  than  to a disease  of the kidneys,
and that the infiltration of the kidney, which we have  examined as the
eighth form, is  evidently developed as  a sequel  of the cachexiae which
we shall shortly investigate, and in  complication with similar  affections 
156
ABNORMITIES  OF
of other organs (liver, spleen).  Although Ave might offer numerous  ob-
servations on this connection, the real cause of the development of the
renal disease from the crasis of the blood, Avhich often takes place with
such extreme rapidity, is to us an enigma.   We look upon the anoma-
lous condition of the blood in Bright's disease as the primary affection,
which, from a peculiar relation to the kidneys, is followed by the se-
condary and visible  disorganization  of the renal tissue; this need  not
hoAvever ahvays ensue, at  all events it  does not follow as rapidly as  the
structural disease of the kidney, consequent   upon the vegetative  dis-
turbance that causes diabetes mellitus.  By this means we explain hoAV
it happens that the two kidneys are generally attacked at the same time
or at brief intervals.   Graves is of opinion that the change of texture is
induced by the free acids  of the urine  (phosphoric and nitric acids) coa-
gulating the albumen as it passes  into the urinary tubuli.
  Bright's  disease is distinguished in the dead and the living subject
by the following symptoms :
  a. We may briefly enumerate the following as occurring in Avell-marked
cases in the kidneys  themselves,—increase in the size and weight of the
organ, and especially of the  cortical substance  (the hypertrophy of
French authors, a term which may easily give rise to a misapprehension);
anaemia, pallor, laxness of the tissues,  development of peculiar granula-
tions, inflammatory sympathy of  the renal fascia, on the one hand,  and
of the mucous membrane of the pelvis and calices, on the other.
  /?. The so-called consecutive symptoms: a constant and considerable
amount of albumen in the urine, accompanied by a diminution of its spe-
cific gravity (Gregory), a  symptom considered by Rayer as belonging to
the chronic form only ; a reduction of the  solid  constituents, Ariz. the salts
and urea, a milky turbid appearance, or if tinged with blood and blood-
corpuscles,  dark discoloration, eminent serosity of the blood arising from
the removal of the albumen, and  accompanied by a diminished specific
gravity of the serum ; dropsy,  Avhich is chiefly manifested as anasarca,
marked pallor of the surface, and secondarily as serous effusion into the
serous cavities, and  especially  of the  pleura  and peritoneum.   Of the
latter symptoms the albuminuria and  the dropsy have long since been
the special  objects of explanatory attempts.
  Albuminuria is considered by Gregory as pathognomonic only when the
specific gravity is simultaneously diminished ;  it seems to  ourselves to
consist in a disturbance of the catalytic function of  the kidney arising
from the homologous infiltration of the renal tissue ;  albumen is in part
deposited in the channels  of the urinary tubuli themselves, as a product
of the reaction.   There is not, however, a proportionate relation between
the degree  of the albuminuria and the amount of renal disease as we may
even find the former existing without the latter.
   Sabatier, whose views are not materially controverted by Rayer's ob-
jection, attributes the dropsical affections  to an attenuation of the blood
produced by the removal  of the albumen.   This crasis of the blood must
therefore, be viewed as secondary.
   The lower degreesof Bright's disease are curable by resolution, without
leaAing any traces, like other moderate inflammatory processes.  In the
advanced stages a cure may be effected, but only with considerable altera- 
THE  KIDNEYS.
157
tions  of texture, as manifested in atrophy of the kidney with a racemose
surface, varicosity of the vessels, cellulo-fibrous condensation of the tissue,
fibro-lardaceous thickening of the renal fascia, and contraction  of the
pelvis and calices, in induration of the product, and its conversion into a
contractile callus.  A  fatal termination is induced, with a greater or less
rapidity, by dropsy, and  especially by serous accumulations in the large
cavities of the body, by the slow or sudden supervention of serous effu-
sion into the ventricles of the brain, into the cerebral substance, and into
the pulmonary parenchyma, by anaemia, by the retention of urea in the
blood, or by morbid conditions of other tissues and organs, which present
accidental or  essential complications with the renal disease and its pre-
disposing  cause.
  In the case of retention of urea in  the  blood, the resulting symptoms
are owing to the antagonism between  the  urea and the nervous matter ;
they consist in coma, delirium, convulsions, and tetanus,  and are not un-
frequently caused by urinous  effusions within the cavity of the cranium.
  The complications are chiefly dependent upon causes that operate sud-
denly or repeatedly, and for a considerable period, such as catarrhs, and
particularly bronchial  catarrh, rheumatism, with or without endocarditis,
and their sequels ; the complications may also originate in the secondary
disorganization of the  blood, and here again we meet Avith catarrhs, and
also with  extensive exudative processes, both  on the mucous membranes
(serous  diarrhoea, pneumonia),1 and, more  especially, on the serous mem-
branes, the arachnoid, pleura, peritoneum, and internal coat of the blood
vessels  (phlebitis).   Hemorrhage and  apoplexy are of rarer occurrence.
There is great difficulty in accounting for  the complication with granular
liver, and with the ascites resulting from the latter affection.   The super-
vention of Bright's disease as a new  complication may probably be ac-
counted for by the  greater liability of a  previously diseased  subject to
the reception of noxious influences, whether operating continuously or
temporarily ; we allude more particularly to the abuse of spirituous liquors,
and to cold.
  The commonest and most evident cause of Bright's disease is cold, the
sudden  or constant  influence of cold  damp air, more especially; at all
events,  the occurrence of Bright's disease  after scarlatina in children and
adults,  is  most frequently due  to this cause;  the abuse of spirituous
liquors is  also considered as a cause, though chiefly in connection with the
previously mentioned influences; diuretics, though they do not originate,
undoubtedly promote the disease.
  Numerous dyscrasic momenta are  of considerable importance.   We
advert  to  the  development of Bright's  disease,  subsequent to exanthe-
matic fevers, particularly scarlatina, to typhus, to tubercular disease and
tubercular suppuration, e. g. pulmonary phthisis, to cancerous diathesis,
and to the affections Avhich  we are about to consider in connection  with
the eighth form.
   The eighth form invariably sets  in without reaction, and springs  from
inveterate scrofulous  or  rickety disease,  but especially  from syphilitic
and mercurial taint.   It presents itself as a constitutional infiltration of
1 [Qy. Bronchitis?—Ed.] 
158
ABNORMITIES  OF
the kidney, and is associated with analogous affections of the spleen and
liver, in the shape of lardaceo-albuminous infiltration; both the nature of
this product and the anomalies of the blood and the urine as yet remain
a perfect enigma.   We have once noticed the complaint as a sequel of
intermittent fever combined with a similar condition of the spleen. ^
  4. Beposits in the kidneys.—The same circumstances that give rise to
deposits or metastases in the lungs, the liver, and the spleen, may induce
them in the kidneys.  They follow inflammations of the endocardium,
and of the lining membrane of the vessels brought on by infection of the
blood,  arising from absorption of the  inflammatory product, or they re-
sult from suppuration and gangrene of membranous and parenchymatous
tissues produced in a similar manner,  or lastly they originate in  sponta-
neous pyaemia.   We would again direct especial attention to the deposits
arising from endocarditis, as  they have not only been overlooked, in the
same Avay as those occurring in the spleen have been, by the most dis-
tinguished inquirers, but as of late Rayer has  interpreted them falsely,
and has viewed them as symptoms of rheumatic nephritis.
  They are found in endocarditis, generally coexistent with similar de-
posits in the spleen, consequent upon primary phlebitis with a purulent
exudation, or upon the absorption of pus or sanious matter from ulcera-
ting surfaces or abscesses; they co-exist with deposits in the lungs, the
liver, the brain, the subcutaneous, and intermuscular cellular tissue, the
interstitial cellular layers of the intestines,  and with secondary phlebitis,
in the most different portions of the venous system.
  There may be only a few, and  in  endocarditis we generally find one
only, or they are as under  the last-named conditions, very numerous;  in
rare cases the kidney is entirely gorged with them.
  They occur chiefly in the cortical substance, and here again mainly in
its peripheral strata; so  that they are at once apparent on the removal
of the fascia  albuginea;  it is only in exceptional cases, and when they
are very numerous, that  they occur in the  pyramids.  They vary much
in size, from  that of an  almost imperceptible  poppy-seed, to that of a
millet- or hemp-seed, of  a pea, a bean, or of a walnut;  the larger ones
present the peculiar form described in the section on the spleen, as exhi-
biting a pyramidal shape, the base of which is directed  towards the sur-
face, the apex towards  the interior of the organ; the smaller ones appear
as rounded nodules.  The intermediate sizes are the most frequent, but
when very numerous, they generally remain so small as scarcely to exceed
the size of millet-seeds.
  They commence in the renal parenchyma as dark-red indurated spots,
which correspond in extent to the above-mentioned sizes; they gradually
assume a dirty broAvn, yellow, or yelloAvish-white color, and are surrounded
by  a light-red inflammatory halo, which indicates the reaction set up in
the adjoining tissue, or if the disorganization advances to a high degree,
by  a dark-red,  discolored ecchymosis.   The latter appearance is coinci-
dent with a very large  number of the  deposits, and as we have seen that
these must then be very  small, we find the renal tissue presenting in the
advanced stage of the disease very numerous small red spots, in the centre
of which an almost imperceptible yellowish-white spot is discovered.
  The further progress of the disease consists in a conversion of the de- 
THE  KIDNEYS.
159
posit into a purulent  or  sanious fluid, and the abscess  may be enlarged
by an analogous transformation of the inflammatory halo; the metamor-
phosis may, however, be benignant, and the deposit become pale, and
shrivel up ; it may then, together with the involved tissues, be absorbed,
or partially retained as a pulpy or cretaceous mass, having a cicatriform
cavity with a fibro-cellular investment, or a fibro-cellular callus, which
corrugates and draws down the surrounding  parts; a greasy yellow sub-
stance or chalky concretion is found buried  in  the  callus, and  like the
investment of the first-mentioned cavity, this is agglutinated to the tunica
albuginea.
   The deposit is essentially an exudative process, the product of which
undergoes the described metamorphoses; or it  depends upon stasis and
coagulation of the blood in the capillary vessels, and a  conversion of the
fibrine in the manner above described,—a secondary angioitis (phlebitis)
capillaris.   Both metamorphoses are known  to be induced by something
that is taken up by the blood; and we thus generally see deposits in the
kidneys resulting from endocarditis, which go through  the second meta-
morphosis, and heal with loss  of substance of a small section of the corti-
cal tissue.
   In the case of  solitary deposits, the parenchyma, with the exception
of that adjoining the morbid  product, does  not participate in the local
process;  when they are very extensive, reaction takes  place throughout
the organ, and is evidenced by tumefaction,  enlargement,  softening, and
and infiltration of the parenchyma; even the mucous membrane of the
urinary passages appears congested, reddened, and softened.
   5.  Morbid growths,  a. Fatty deposit in the  kidneys.—We shall exa-
mine this subject under the head of Hypertrophy of the Fascia Adiposa.
   b.  Formation of cysts.—Although we explicitly exclude the considera-
tion of all encysted tumors Avhich have their origin in a dilatation of the
urinary passages,  and especially of  the calices,  we think it necessary at
this place to discuss—
   a.  Cysts, that occur frequently in the renal parenchyma, and which we
cannot positively state to be neAv formations. We allude to  cysts which
vary  in size from that of a millet-seed, pea,  or bean, to that  of a Avalnut
or even a goose's egg, and which  contain a clear, colorless, or yelloAvish,
serous, alkalescent matter, or a substance of a yelloAvish or brownish
color, and of  a melicerous or mucilaginous  consistency, or  again, of a
lateritious,  chocolate-colored or inky (melanotic) tint.   They are formed
by a  serous membrane, in  which a branched vascular  network  may be
traced.  They vary in number; sometimes there is a solitary cyst of one
of the above-named sizes ; generally there are several of different sizes ;
and in rare cases, they are so numerous, that the kidney, being  propor-
tionately enlarged, appears converted  into a collection of cysts varying
both  as  to size and to contents, the renal tissues having given way to
them.  In very well-marked cases a diminution of the urinary secretion,
and its consequences, have been observed.   These cysts  are  chiefly de-
veloped in  the peripheral layer of  the  cortical substance, and  project
above the surface of the kidney,  so as to be at once perceptible on the
removal of the tunica albuginea.
   They occur at every period of life, and are sometimes even congenital. 
160
ABNORMITIES  OF
They acquire additional importance if developed in consequence of renal
inflammation, especially when this arises  from lithiasis, and more par-
ticularly in consequence of Bright's disease.
  Our own view, and that of German authors generally, is that they are
not the dilated terminations of the Malpighian capillary tubes, but that
they consist in a conversion of the cellular layer in the Malpighian cor-
puscles into serous cysts,  resulting  from the pressure  exerted  by the
Malpighian corpuscles when tumefied and gorged with the  inflammatory
product of these diseases upon the surrounding strata.  The latter during
their metamorphosis take up the vessels of the renal coil (Nierenknauel)
for  the purpose of the neAv secretions.   It would not be surprising if
their contents were occasionally urinous, but we have never been able to
discover a trace of urinous precipitates or concretions in them.  We have
once found a cyst that Avas seated at the circumference, and was of con-
siderable size, inflamed and ruptured, and its contents effused into the
adipose layer.
  /3. The acephalocyst is a morbid  product that occurs in the kidney  ;
less frequently certainly than in the liver, but more frequently than in
any other organ.  We have no  particular remarks to offer in  reference
to the relations of this  variety  of encysted tumor,  to its contents, or to
the surrounding tissues, except that it occasionally reaches the extraordi-
nary size of a fist or  a child's head, and that  it may discharge its con-
tents in various  directions.  The following modes  of discharge  are im-
portant :
  aa.  Communication of the cyst with,  and its discharge into,  the colon
(the ascending or  descending colon), and consequent  evacuation  per
anum, and
  /S/3.  The communication  of the cyst  with, and its discharge into, the
cavity of the renal pelves and calices.  Small acephalocysts, or ruptured
larger ones, may thus be conveyed by the ureters to the bladder, and be
evacuated, as is particularly the case with females, by the urethra (mictus
acephalocysticus), or they induce  obstruction  and  dilatation  of the
urinary passages by their size.
  y. The composite cystoidea rarely occur in the kidneys ; though when
they are formed, they attain a considerable size.   We have in our mu-
seum an illustrative specimen, in the left kidney of a boy of five years
of age.
   e. Anomalous, fibrous, and osseous tissue.—We  find fibroid masses of
various^extent and shape developed in the products left by inflammation
and Bright's disease ; and in rare cases a deposition of osseous substance
is effected within them, in  the same manner as we find occurring in the
fibrous exudations of serous membranes.  The  calcareous concretions are
not however in this case laminae, but irregular tuberculated masses.  We
also find that a fibrous tissue of recent formation constitutes the external
layer of the acephalocysts and  composite cystoidea, as well as the base
and fundamental structure of cancerous growths in the kidneys.
   d. Tubercle.—Tubercle exists in the kidneys under two distinct con-
ditions ; in  both, however, the cortical substance is the chief seat of the
deposit.
   a.  In one case, it is the  result of a very high degree  of  tubercular 
THE  KIDNEYS.
161
dyscrasia; a partial symptom of the development of tubercular disease
in many or the majority of organs, and, in that case, frequently the pro-
duct of a very tumultuous process of deposition. The tubercles are found
to exist in great numbers,  and occur in the shape of grayish-white, deli-
cate vesicular,  or larger, i. e. miliary granulations, surrounded by con-
gested  and  ecchymosed parenchyma.   The  entire viscus  is  swollen,
gorged, and softened; it is hyperaemic, and either darker than ordinary,
or paler and  infiltrated, and the mucous membrane of the urinary pas-
sages is reddened and injected.  If the morbid process takes place with
less intensity and has a more  chronic duration, the tubercular matter is
found  in less quantity, of the  size of millet- or hemp-seeds, and sur-
rounded by pale tissue, which presents no trace of reaction either in the
vicinity of or at a distance from the tubercular deposit.
   This form  of renal tubercle occurs as a complication of tubercular de-
posit in most parenchymatous organs and membranous expansions; and
especially in  conjunction with tuberculosis of the abdominal viscera, and
more particularly of  the spleen, the  liver, and the  peritoneum.  Even
when occurring under violent symptoms, it is rarely fatal by itself  by
paralysis of the  renal  functions, but it becomes  so by the universal
affection and by the coexistent disease of other organs.  This variety  of
renal tubercle, even when  its  progress is less rapid,  rarely proceeds fur-
ther than to  a  yellow discoloration, and never  advances to actual fusion.
Both kidneys are commonly attacked uniformly.
   J3.  In the other case,  renal tubercle is a partial appearance of tuber-
cular disease that is limited to the male urinary and sexual organs.   It
then generally attacks the testes and the  allied lymphatic and prostate
glands primarily, and extends from these to the urinary apparatus, i.  e.
the mucous membrane of the entire tract, to the kidneys, and, lastly,  to
the supra-renal capsules.  It is commonly viewed as possessing a blennor-
rhoic character or as gonorrhoeal tubercle; but post-mortem examina-
tions have not  established the fact by demonstrating any peculiarity  in
the tubercular  deposit.   It very often supervenes upon a previous tuber-
cular condition of the lungs, or the latter, as  well  as tubercle in  other
organs, allies itself to the advanced stage of renal tubercle.  This variety
of renal tubercle frequently reaches a high  degree  as regards the num-
ber of the tubercles, and their gradual accumulation into extensive groups
and coalition into large  masses.  The viscus is found to  have increased
in size  and is nodulated, and the tissues in the vicinity of the tubercle,
or throughout the organ, are in  a state of chronic reaction, and appear
pale  and dense, and infiltrated with  lardaceous matter, and the tunica
albuginea is thickened.  This form of renal tubercle frequently passes
more or less rapidly into the stage of softening, giving rise to tubercular
ulceration (vomica renis tuberculosa), tubercular suppuration, and tuber-
cular phthisis of the kidneys.
   The disease generally  attacks one kidney only  in  a very extensive
degree.
   e.  Carcinoma.—Carcinomatous growths occur  frequently in the kid-
neys, and in the primary form.   This is particularly the case with me-
dullary cancer, which we find  attaining a very large  size, whereas areolar
and hyaline cancer are extremely rare.  Of these, we have observed the
  VOL. II.                          11 
in2
ABNORMITIES  OF  THE  KIDNEYS.
 former only twice, in combination with medullary cancer, and the latter
 only as a secondary affection accompanying universal cancerous deposit.
   Medullary cancer appears either in the shape of more or less numer-
 ous  distinct, rounded, circumscribed masses, varying in  size from that of
 a pea to that of a Avalnut and a hen's egg, of dense or  soft texture (en-
 cephaloid), white or variously colored (melanotic); these circumstances
 generally attend the rapid development of universal carcinomatous de-
 position, and therefore indicate secondary cancer of the  kidney;  as a
 primary affection, it appears in the shape of a carcinomatous tumor, ac-
 companied  by  partial infiltration and  degeneration of the adjoining
 tissues ;  this tumor  rapidly increases  to the size of a child's or adult's
 head, forming  rounded nodulated masses, which  perforate the fibrous
 sheath, extend  to  the peritoneum, the lymphatic  glands of the  lumbar
 plexus, and involve the periosteum and ligaments of the abdominal ver-
 tebrae ; the diseased tissue thus becomes fixed, after which occurrence it
 grows into the cavity of the renal pelves and calices, the renal veins and
 the vena cava,  and causes their obturation.
  The latter variety generally remains the focus  of the carcinomatous
 cachexia and the sole cancer occurring in the body, on account of its ex-
treme vegetative power; yet we not unfrequently discover in its vicinity
and  especially on the peritoneum, the  diaphragmatic pleura of the dis-
eased side, and in the liver, isolated cancerous deposits.
  An  important complication, and one that points to an  analogy with
tubercular disease, is that with medullary cancer in the testicle of the
same side.   The two commonly coexist, or the renal cancer is developed
shortly after that of the testis.
  We have noticed the disease not only in the middle period of life, but
both in advanced age and in early youth (as early as in the fifth  year).
Both kidneys appear equally liable to the affection.
  When the growth is effected with great violence, hyperaemia and he-
morrhage not unfrequently occur in medullary carcinoma of the kidney,
and  when it extends into  the urinary passages, we find that blood is
effused into them also.
  6. Anomalous Contents.—Besides  the anomalies already alluded to,
Ave have to advert to the following morbid contents of the urinary cana-
 liculi.
  a.  The formation of calculous  urinary  concretions, which  appear in
the shape of delicate granular crystals, dispersed through the substance
 of the kidney, and which consist of lithic acid.
  b. Entozoa;  these are, besides the animalcules inhabiting the acephalo-
 cyst, the cysticercus and the very rare strongylus gigas.

  §  8. Special  disease of the Investments of the Kidneys.
  1. Hypertrophy of the adipose layer—The  adipose tissue which sur-
 rounds the kidneys may increase in quantity coincidently with a universal
 increase of the  fat of the body, or it may become hypertrophied by itself*
 in the latter case it may increase to such an extent as  to force  its way
 into the hilus of the organ,  impede its nutrition, and cause a fatty infil-
tration of the kidney, accompanied by anaemia and pallor.  It  appears
 that rare cases of this  description have  been occasionally taken for
 Bright's disease, and this  has given rise to  the latter being thought ana- 
            DISEASES  OF  THE  URINARY  PASSAGES.        163

logous to fatty liver.  When it has advanced  to  the  highest stage, the
kidney presents the appearance of  a mere piece of fat surrounded by a
mass of  adipose tissue, and without the slightest traces of renal  organi-
zation ; the urinary passages at the same time are atrophied and obli-
terated.
   Independently of universal adipose deposit, we find a larger or  smaller
excess of  fat enveloping the kidneys  of old  people,  accompanied  by
atrophy  of the organ;  it also  accumulates when  the  kidney is affected
by moderate but lasting  inflammatory irritation,  especially that  caused
by calculi, and in secondary atrophy, and obliteration of the kidney.
   2. Perinephritis.—This comprehends inflammation of the tunica albu-
ginea and of the fascia adiposa of  the kidney.   It results from wounds,
concussion, and urinous infiltration, and accompanies both the inflamma-
tion  of the kidneys and that of the pelves and calices.
   Inflammation of the tunica albuginea is characterized, as we have al-
ready had occasion to state, by development of the vessels of the  cortical
substance, by congestion and softening, succulence and  condensation of
its tissue, and by the facility with which it may be detached.  It is always
combined with inflammation of the  cortical substance of the kidney.  It
is only when the latter terminates in suppuration that the disease in ques-
tion  has a similar issue; but it frequently leaves a fibroid thickening of
various  degrees, combined with induration,  atrophy, and obliteration of
the kidney, resulting from inflammation of the  organ.
   Inflammation of  the fascia adiposa, which is  particularly apt to super-
vene upon the tedious inflammation of the  kidneys and their pelves, in-
duced by calculous  irritation, has the general characters of inflammation
of fatty tissues ; it induces condensation and rusty  discoloration ; atrophy
and  conversion of  the fat into a white or  slate-colored cellulo-fibrous tis-
sue,  which forms adhesions with the thickened albuginea and the perito-
neum ; in some cases suppuration and abscess may ensue.

           SECT. II.—DISEASES OF THE URINARY PASSAGES.

   § 1. Befect and  Excess of Formation.—It is self-evident that where '
one kidney is deficient, the corresponding portion of the urinary passages
must be  entirely, or at least partially, absent; but when the kidneys are
present,  exceptional cases occur in  which the ureters terminate in a cul-
de-sac in the vicinity of the bladder, and also in the neighborhood of the
pelvis of the  kidney ; or we may find in addition to a perfect ureter, a
rudimentary one developed at the bladder; or finally, the apparatus may
have undergone an  arrest of development, and be very narrow, and have
very delicate coats.
   If the kidneys are increased  in number, the urinary channels are also
multiplied; but more frequently the apparent excess is owing to fissure;
the calices opening into two or three pelves, which, in their turn, discharge
themselves into two or three ureters.  In a less marked degree there is a
single pelvis, which is divided inferiorly so as to open into two ureters ;
occasionally, these  are also found  to  form partial  subdivisions.   This
malformation, and particularly the  fissured  pelvis, which is then found
partially detached  from the  organ, frequently accompanies a defective 
164
DISEASES OF THE
development of the hilus of the kidney ; it also coexists with an elongated
state and a transverse division of the kidneys.
   The relation of the vesical orifice of the fissured ureters to the bladder
varies.   They  generally coalesce in the neighborhood of the bladder, or
within its coats, so as to form a single channel, which communicates with
the cavity of the bladder by a single mouth;  they rarely open by sepa-
rate orifices placed behind  one  another at one  side  of the trigonum
Lieutaudi.
   When the kidney occupies an irregularly low position, the  length of
the ureter is correspondingly diminished.

   § 2. Beviations of Calibre.—The deviations of calibre consist in dilata-
tion of the urinary passages, caused by accumulations of urine, which
result  from  obstacles  to its discharge,  and frequently  favored  by an
inflammatory condition  of the mucous membrane, which paralyzes  the
external contractile layer.   It will depend  upon the position of the im-
pediment whether  the dilatation affects a larger or smaller section of the
apparatus.  If the former occupies the vesical  orifice of the ureter, the
entire ureter, the pelvis, and lastly, the calices, become gradually dilated;
it is evident, as we shall subsequently examine more fully, that more dis-
tant impediments, as, for instance, those placed in the urethra, must also
induce dilatation.
   The degree in which the dilatation occurs is very various;  the higher
degrees offer on their own account, as well as on account of various con-
secutive anomalies, numerous points of interest.   Dilatation of the pelves
and calices, by exerting pressure  upon the renal substance, induces atro-
phy of the latter.   The  papilla is first reduced ; it  becomes condensed
and coriaceous, and gradually disappears in  the arch  of the  expanded
calyx; the superimposed renal tissue at the same time diminishing in
thickness, becoming denser, and assuming a leathery toughness.   At an
advanced stage the substance of the kidney may be only one, or a few
lines in thickness,  and even disappear altogether, being converted into a
mere membranous  sac (hydrops renalis, Rayer's hydronephrose), Avith an
external lobulated  appearance, presenting cells within,  and  filled with a
urinous,  variously  sedimentary fluid, or with clear serum ; the loculi may
intercommunicate with one another, in consequence of atrophy or rupture
of the contiguous parietes.   These sacs  sometimes attain, especially in
cases which are unaccompanied by inflammation, the size of a child's or
an adult's head; but there is no  doubt that, after  the  urinary secretion
has ceased, in consequence of atrophy of  the renal tissue, and  especially
of previous inflammation, they may be reduced.
   Dilatation of the ureters  exhibits  every  possible degree;  the ureter
may even attain the size of the small intestine.   It is then found hyper-
trophied, inasmuch as its parietes not only present the average but even
increased thickness ; and as it is increased in  length, and consequently
instead of being straight, appears coiled or bent.  At the same time  the
dilatation is  not uniform, as  several portions of the ureter are narrower
than  others, the  external cellulo-fibrous tissue accumulating at these
points during the dilatation,  and  offering  resistance.  To this fact also
is  owing the peculiar direction the ureter assumes, as  the curvature  or 
URINARY  PASSAGES.
165
flexure always occurs at these spots.   It may also  be observed that the
tube rotates upon its axis at these points, a circumstance which  further
adds to  the diminution of its calibre, and  offers a new obstacle.  The
parietes of these cavities and canals always  bear, as we ^have already
remarked, that proportion to the dilatation, that they must be considered
hypertrophied ; they only attain a remarkable and extravagant thickness,
however, if there is concurrent inflammation.
   The following circumstances may induce the occurrence of dilatation:
Compression of the ureter at different points by morbid growths, by the
impregnated uterus, especially by cancer of the womb which extends to
the bladder, by fibroid tumors of the uterus, by enlarged, and particularly
by dropsical,  ovaries, by accumulation of urine in  the bladder itself, or
by lasting contraction  of the bladder consequent  upon hypertrophy of
its coats;—contraction  of the ureter from tumefaction  of its coats, con-
sequent  upon inflammation  and its results ;—obliteration of the ureter,
and obturation of the calices, the pelvis, and ureter, by calculous  concre-
tions ;—cancerous growths forcing their way inwards from without; and,
finally, numerous morbid  conditions of the bladder,  the prostate, and the
urethra, which impede the discharge of the urine into the bladder, or the
evacuation of the latter.
   These dilatations are consequently generally acquired in advanced life,
though in the case of original occlusion (blind termination) of the urinary
passages, they may be congenital.
   In a particular case that we have observed, the  pressure  exerted by
an irregular branch  of the emulgent artery, of one  line  in diameter, that
descended from the upper end of the hilus, so as to form an arch over
the convoluted transition  of  the pelvis to the  ureter on  the right side,
caused a dilatation of the former.
   The contractions of the urinary passages  are sufficiently explained in
the above; they are also the result of renal  atrophy, and may amount to
complete obliteration and closure of their calibre.

   § 3. Anomalies of Position.—As  a congenital  anomaly,  we mention
the detached position of the single or multiplied pelvis of the kidney ac-
companying  an  imperfectly developed state of the renal  labia, and
especially occurring  in cases  of anomalous formation and position of the
kidney:  acquired anomalies of  position are  brought  on by  pressure
exerted upon the ureter by irregularities of the neighboring organs.

   § 4. Anomalies of Texture.—1. Inflammation of the urinary passages
have to be first mentioned, and especially—
   a. Catarrhal inflammation, both on account of its frequent occurrence,
as on  account of its  consequences and its transition to  the substance of
the kidneys.   As a primary  disease, it appears in  the  shape of inflam-
mation  of the renal pelvis and  the calices (pyelitis), with inflammation
of the kidney, as may be gathered from the description  of nephritis and
Bright's disease; it  may be  secondary, owing to irritation  exerted by
accumulation of urine and urinary concretions on the mucous membrane
of these parts (pyelitis calculosa);  and it may also  be and very often is
metastatic, the inflammation of  the  bladder being  transferred  to the
ureters, the pelves, and  calices. 
166
DISEASES  OF THE
  It is either acute, as in the case of complication with  acute nephritis,
or more commonly chronic, being maintained by lasting  and repeated
noxious influences, or being the result of a chronic morbid process in the
bladder, in which case we meet Avith  temporary acute exacerbations.  It
is of extreme importance, and renders the following details necessary.
  The characters are, in proportion  to the degree of intensity and dura-
tion, a dusky reddish or brown-red congestive state, similar or ashy dis-
colorations in the shape of solitary spots or  islands,  or of extensive con-
nected patches, tumefaction and villosity of the mucous membrane, and
secretion of a yellow puriform mucus, blennorrhoea.
  The longer the inflammatory condition lasts, the  more the gradual di-
latation of the urinary passages, with hypertrophy of the membranes,
increases, both in consequence of the paralysis of the external contractile
and irritable layer as from the accumulation of the renal and the morbid
mucous secretion.
  At an advanced degree, as in the temporary exacerbation of  chronic
inflammation, the mucous membrane, particularly when subject to irrita-
tion by gravel and calculi, which  chiefly affect  the calices and pelves,
appears  of  a  saturated  red color,  considerably swollen, spongy,  and
friable; a purulent, more or less sanguineous, fluid is secreted (superficial
suppuration), the surrounding cellular and adipose tissues are traversed
by varicose  vessels, and infiltrated.   We find that moderate catarrhal
inflammation of the ureters gradually extends  to the kidney in the shape
of chronic inflammation;  it equally  attacks the kidney with tumultuous
symptoms as acute inflammation when it has reached this advanced degree,
and thus proves  fatal.
  The above-mentioned high degree  of inflammation is also found to pass
into suppuration of the urinary passages, which spreads from the calices
to the tissue of the kidneys, and causes in  the latter the formation of
abscesses or extensive ulcerative destruction, occasionally urinous infiltra-
tion of the renal parenchyma,  gangrenous ulceration, and gangrene of
the calices  and  pelvis.   We thus find it gradually proceeding in the
ureters  to perforation, slow infiltration of urine  in the adjoining tissues,
inflammation, suppuration, necrosis,  and in fortunate cases, formation of
circumscribed abscesses with indurated parietes.
  In  these various conditions, the urinary passages  contain  an alkaline
urinous fluid of a pungent odor, which is variously discolored; it is mixed
up with puriform mucus or true pus, sanies, blood, and portions of broken-
up tissue, and it frequently deposits a sedimentary incrustation upon the
inflamed mucous membrane.
  In  rare cases the advanced  stages of the  disease  terminate favorably
in obliteration of the urinary passages.   After the cessation of the urinary
secretion, consequent upon  complete atrophy of the renal tissue from
pressure exerted by the dilated renal calices, or  more frequently conse-
quent upon  the coexisting chronic inflammation of the kidney, the tissues
contract, the parietes become thickened, and the calibre of the passages
is gradually reduced, till  complete obliteration  results.   The fluid con-
tained in the cavity of the calices, which consists of blennorrhoic mucus
pus, and urine, the latter being strongly impregnated with alkalies, salts
of lime, and particularly with phosphates, first causes an incrustation on 
URINARY  PASSAGES.
167
the parietes of the calices, and then becomes inspissated, so as to form a
grayish or yellowish-white, greasy, and chalky pulp, Avhich fills  the ca-
lices ; the kidney thus presents the appearance of a loculated cyst, the
compartments of which contain the pulp, and radiate from the hilus to
the circumference.   This pultaceous substance is in due course converted
into a dry mortar-like, gritty, dense, calculous mass, and the tissues con-
tracting at the same time, the sac is reduced, the kidney and the efferent
channels are obliterated.   Occasionally this  metamorphosis is  observed
to take place in one or more detached calices.
   Occasionally laminated, corded, nodulated, and  amorphous  bony con-
cretions are formed in the membranes of the renal calices and  pelves,
after these have been previously converted into a fibroid or cartilaginous
tissue by the inflammatory process; the same may occur  in the  ureter,
though we have not observed it ourselves.
   b. Exudative inflammation.—This  is on the whole an unusual occur-
rence, and as far as we are able to judge, invariably a secondary affection;
we have never met with a case of idiopathic croup  of the urinary organs.
It is found complicated with products of the most various plasticity, fol-
lowing typhus, exanthematic diseases, more especially variola and scarla-
tina, exudative processes in other tissues, as diphtheritis and acute tuber-
culosis, and purulent infection of  the blood; it is very frequently the
consequence of  extreme disorganization of  the  blood (especially the so-
called status putridus), and then appears as hemorrhagic exudation with
purple or dark-red  discoloration, sanguineous infiltration, friability and
solution of the mucous tissue, and  hemorrhage.  It may extend over a
large surface, or be confined to isolated spots, and it not unfrequently
implies gangrene.
   2. Morbid growths.—a.  Fibroid tissue and calcareous concretions re-
sult from chronic inflammation of  the  urinary passages in the manner
above described.
   b. Cysts appear to be more frequent in the urinary passages than they
are in and upon other excretory ducts.   Without referring to older cases,
we may notice  two that have been  observed in  the Vienna Hospital.
They represent  cysts of the size of millet-seeds or peas, developed under
the mucous membrane,  and either grouped together or solitary, contain-
ing a colorless or yellowish serous fluid, in which is found a soft glutinous
or hard nodule, varying  in  size, and resembling amber  or horn; these
cysts and  the mucous covering occasionally burst,_ which is proved by
the concretions  having been discovered unattached in the bladder. They
were found chiefly occupying the ureters, and in one case the pelves and
calices of the kidneys.
   c. Tubercle.—-This occurs as tubercular affection of the mucous mem-
brane, and is  always a symptom of tubercular  disease  that has spread
from the male genitals to the urinary organs.   The  earlier stages  and
the chronic course  of the disease are marked by gray millet-sized granu-
lations in the submucous  cellular  tissue, which speedily become  yellow,
soften, and after perforating the mucous membrane within a ring of re-
active inflammation, give rise to small circular ulcers, which but  rarely
enlarge to the dimensions of a pea or a bean.  When the  disease sets in
with great violence, the mucous membrane is attacked in larger  sinuous 
168
ABNORMITIES  OF  THE
or annular patches, or becomes infiltrated throughout with the tubercular
product of inflammation, which is at once detached as a cheesy purulent
mass.  The mucous membrane is, under these circumstances, converted
into  a thick, yellow, fissured,  and purulent  layer, the external cellulo-
fibrous layer of Avhich presents a lardaceous character; the  calibre  of
the canal is  enlarged.  At those parts which are not  affected, by this
degeneration, we not unfrequently find numerous aphthous erosions, re-
sembling those  observed in pulmonary and laryngeal phthisis.
   Tubercular suppuration occasionally passes from the pelvis of the kid-
ney to its parenchyma, and it  here not unfrequently meets with soften-
ing tubercles, or even with tubercular abscesses.
   d.  Cancer.—Cancer occurs very rarely as  a primary disease of the
mucous membrane of the urinary passages, and never except in company
with one or  several cancerous  formations in other organs  already in a
process of development;  in these cases it affects  the  calices  and pelvis
of the kidney, and chiefly assumes the medullary or fungoid form.
   The parietes of the urinary  passages are very often involved in a secon-
dary degeneration  by the encroachment of cancerous growths from with-
out ;  the calices and pelvis being attacked by carcinoma of the kidney,
the ureters by cancer of the uterus.  Their  cavities are narrowed by the
cancerous products, and even entirely closed up.

        SECT. III.—ABNORMITIES OF THE URINARY  BLADDER.

   § 1. Befect and Excess of Formation.—Arrest of development occurs
in various forms and degrees.
   Complete defect is a very rare occurrence; we may meet with it accom-
panying  a very imperfect development of the kidneys, with  absence  of
the urethra, and commonly also  as a complication of formative  defects
of other  organs.    If, under these circumstances, the  ureters are well
formed, they open at the navel,  into the rectum,  or the vulva.
   Occasionally the bladder is  very small, whilst the other  portions of
the urinary apparatus are of normal size; its parietes  are  then imper-
fect ; it  is, in fact, represented by a delicate mucous  bag, a mere dilata-
tion of the ureters.
   The various  fissures of  the  bladder are other forms of arrest of deve-
lopment.  We  allude, first to  the very rare  cases of fissure or diAision of
the bladder by means of a perfect or an imperfect partition in the median
line,  the so-called  double bladder.  That variety of this species of defect
is much  more  frequent, which  has  been termed, from its appearance,
ectrophia or inversion of  the bladder.   It is the  result of a fissure, or a
defect of the anterior vesical parietes, and is not  unfrequently associated
with fissures of adjoining viscera in the mesian line.   It is  more parti-
cularly accompanied by a defect of the symphysis pubis—in the female
sex by absence of the anterior commissure of the labia and  the clitoris;
in the male sex, by fissure of the urethra on  the dorsal surface of the
penis, or epispadiasis.   In the case of inversion of the bladder, we find in
the hypogastrium,  immediately beneath the navel, Avhich is always placed
very low, a red, mucous, dilated spot, the edges of  which coalesce with
the common integument: in the male sex it passes downwards, so  as to 
URINARY  BLADDER.
169
terminate in the  fissure  of the  urethra;  in the female it  is surrounded
by two diverging tumors which represent the labia, and it  terminates in
the lamina of the general integument which invests the rima vulvae.  The
ureters open upon this mucous surface, and their orifice is generally found
at the inferior half.
  The exposed vesical mucous membrane and, owing to the  constant stilli-
cidium of urine from the ureters, the neighboring cutaneous surface,
become irritated, reddened, and excoriated.  In a very  old preparation
taken from an adult, which has been  transferred from the Anatomical
Museum of the University to the Pathological Collection, I find the former
in a state of fungoid degeneration.
  When the fissure of the urinary bladder occurs  in an opposite direc-
tion, and* is accompanied by fissure of the genital cavities and the rectum,
we obtain the formation of cloacae in their various degrees.   The urachus
may remain- patent to a certain distance from the bladder, or throughout
its entire extent.
  We have also to allude to defective development occurring in the shape
of unusual contraction of the vesical orifice,  or atresia vesicae.
  In  biventral monsters, the bladder is found more  or less  competely
double.

   § 2. Beviations of Size and Form.  Hypertrophy and atrophy of the
bladder.—With the exception of the above-mentioned congenital  small-
ness of the bladder, and  the  congenital  dilatations of the organ from
contraction or atresia of the urethra, the anomalies to  be  classed  under
this head are all acquired;  they are the conditions of  permanent  and
excessive dilatation and contraction.
   Dilatation of the bladder is seen under various forms.  It may be
uniform  and general, and in solitary cases attains  such an extent, that
the bladder is represented by a fluctuating paralyzed sac, with relatively
thickened parietes, filling the entire pelvis and hypogastric region.   It
is caused by accumulation  of urine, consequent  upon insensibility  and
paralysis of the bladder, but  more particularly by mechanical obstacles
in the neck of  the  bladder  and in the urethra;  in the last case espe-
cially, that extreme degree is developed which  is always accompanied by
hypertrophy of the parietes.
  Dilatation of  the  ureters is a consequence of this affection; it proves
fatal  by inflammation resulting from the influence of the stagnating and
decomposed urine upon the mucous membrane,  by the consequent suppu-
ration and gangrene, and especially by peritonitis.
   Dilatation occasionally affects in a greater or less degree certain por-
tions, or predominates in  certain directions ; thus we find  lateral expan-
sions  at  the fundus vesicae, and saccular  indentations  produced by the
pressure of calculi at or posterior to the triangle of Lieutaud.
   An important variety of partial vesical dilatation is  presented to us in
the hernial  dilatation, or acquired diverticulum  of the  bladder.  It is
always developed in a bladder the muscular coat  of which is hypertro-
phied, and this hypertrophy, being accompanied by increased irritability
of the bladder, affords an evident and intelligible explanation for the pre-
disposition.  The vesical mucous membrane insinuates itself between the 
170
ABNORMITIES  OF  THE
fissures left by the rounded or hypertrophied fleshy columns, is gradually
forced  through  them, and forms  saccular appendages to the bladder,
which increase by degrees, and attain a size varying from that of a wal-
nut or hen's egg to that of a fist or a human head.   Their cavity at first
communicates with the bladder by means  of  an elongated rhomboidal
opening, and  the more they increase, the more the latter, being enlarged
at the same time, is converted into a round sphincter.
   These diverticula occur principally at the lateral portions and near the
vertex  of the bladder; they are  also  found  at the posterior  surface,
and may frequently be  seen at all these points at  once.   The diverti-
culum is very rarely developed in the triangle near the perineum.  Its
parietes are formed of the mucous membrane of the bladder, which,
under certain self-evident circumstances, is invested by the peritoneum.
Sometimes a few muscular fibres traverse the diverticulum, which circum-
stance may cause it to be  viewed as congenital.
   If there happens to be  concurrent calculous disease of the bladder,
the diverticula acquire additional  importance, as the  calculi  may pass
into them, or be formed within their cavity, and either be firmly grasped
or float unattached.  The mucous  membrane of small  diverticula is fre-
quently the seat of chronic inflammation, causing a muco-purulent secre-
tion, and followed by ulcerative perforation and the formation of sinuses
between the vesical coats; these sinuses traverse  the trabecular struc-
ture of the muscular coat in  the most various directions.
  Permanent  contraction  of the bladder occurs in various degrees as a
consequence of enduring irritation, e. g. by a calculus ;  or of increased
irritability of the  mucous membrane from inflammation.  The longer
these  influences  last, the  more the parietes increase in thickness and
hardness, so that they not unfrequently present the appearance of a ball
contracted to the size of a duck's or hen's egg.
  The contraction is at times partial, and  may then give rise to a per-
manent coarctation of the  bladder  at one or even at several points.  The
bilocular vesicae,  noticed  by ancient  anatomists, probably  took their
origin in a morbid contraction of this nature.
  As regards the diameter of the vesical parietes, we pass over nume-
rous morbid conditions which give  rise to thickening, and which will be
investigated subsequently, and have now to examine the states of hyper-
trophy and atrophy.
  Both are  most  apparent in the  muscular coat;  hypertrophy  of  the
mucous membrane is chiefly seen in connection with chronic congestion
and catarrh of the  bladder,  and we shall examine into it more fully in
speaking of these affections.
  Hypertrophy of the muscular  coat  takes  place  in consequence  of
catarrhal  affections of  the vesical  mucous membrane;  of repeated and
enduring irritation, especially from urinary  concretions • of excessive
efforts made to overcome obstacles to the discharge of the urine.   The
latter may affect either the neck of the bladder or the urethra and be
caused by the pressure exerted upon these parts  by enlarged or dislo-
cated organs in the vicinity; as by prolapsus, tumors, and degenerations
of the uterus, uterine,  vaginal, and rectal cancer, by the enlarged pro-
state, strictures of  the urethra,  &c.  The  muscular fasciculi  are found 
URINARY  BLADDER.
171
thickened, so  as to form  rounded trabeculae, which project  from the
inner surface of the bladder in the shape of a trabecular network, com-
parable to the inner surface of the right ventricle of the heart (vessie d
colonne), the mucous membrane insinuates itself within its meshes, unless
the  bladder [he permanently contracted,  and finally  forces its way
through them in the shape of diverticula.
   The bladder is at the same time either dilated, or if the irritability of
the mucous membrane is increased, it is contracted.  In the latter case
especially, the entrance of the urine  from the ureters  is variously im-
peded, and thus a dilatation of the urinary passages ensues.
   We must, however, be  cautious not to mistake a bladder with thick
walls, which is perfectly contracted after it has been completely emptied,
for a case of hypertrophy.
   Atrophy of the vesical parietes occurs rarely.  The mucous membrane
may be reduced to a very  delicate,  shining  membrane, resembling the
arachnoid, and the  muscular coat disappears, with the exception of a few
almost imperceptible pale traces; the contractile power of the bladder
ceases,  its parietes are in  a state of permanent relaxation, soft, thin,
transparent, pale, anaemic, and friable.   We have twice observed atrophy
of the vesical parietes of this description as a substantive disease.
   The shape of the bladder is liable to numerous deviations.   All the
congenital malformations  that are connected  with  the above-mentioned
anomalies  of development belong to this head, and as acquired  malfor-
mations,  we may  mention  those accompanying dilatation,  especially
when effected in one direction, and causing diverticula, those resulting
from irregular  and constant contraction, and those assuming the cylin-
drical, cuneiform, or cordate form, in consequence of hypertrophic con-
ditions.

   § 3.  Anomalies of Position.—These involve the  dislocation  of the
bladder from its normal position, and in various directions, by enlarged
neighboring viscera, and voluminous morbid growths in the pelvic cavity,
by contraction and malformation (especially that resulting from mollities
ossium) of the pelvis; the dragging down  of the bladder by dislocated
viscera in its vicinity, especially by the  prolapsed  uterus, and by large
morbid  growths in the perineum, the position occupied by the bladder
in large inguinal, perineal, and vaginal herniae ; the  intussusception of the
bladder in the urethra, and its prolapsus through the latter in females ;
the eversion of the bladder in consequence of a rupture  affecting both it
and the vagina.

   § 4.  Solutions of Continuity.—We class under this head—
   1.  Injuries of the bladder by means of cutting instruments,  including
the surgical wounds caused by cystotomy and puncture  of the bladder;
the contusions  produced by the head of  the child during parturition, by
obstetric instruments, by splinters of  bone arising from pelvic fractures,
or by concussion received  by a fall or a blow ; rupture of the bladder ac-
companied by more or less diffused infiltration of the vesical membranes
and the surrounding cellular tissue, and  hemorrhage.
   2.  The very rare spontaneous  ruptures of the bladder resulting from
excessive repletion and distension of the latter. 
172
ABNORMITIES  OF  THE
  In both cases the termination may vary; in favorable circumstances a
cure may result;  extravasation of urine into the peritoneal cavity and
peritonitis, or urinous  infiltration of the cellular tissue, with diffuse in-
flammation, suppuration, gangrene, and under these circumstances com-
monly a fatal issue, may take place ; or if the secondary processes are
circumscribed, abnormal openings may be established, and vesical fistulae
form.
  3. The ulcerative solutions  of continuity occurring from within  as
well as from  without, together  with the consequent and  frequent  con-
stricted  or patulous communications  between the bladder  and neigh-
boring cavities and  channels, the intestinal tube,  and particularly the
rectum, the uterine and vaginal cavities, abscesses, &c.

  §  5. Anomalies of  Texture.—Here  too the diseases of the mucous
membrane are of main  interest, as those of the muscular coat are rare in
themselves, and when they occur are generally consecutive or secondary.
We shall consider them in their proper places.
  1. Hyperaemia of the Bladder.—Besides the congestion existing as a
stage preparatory to and associated with inflammation, we  find hyper-
aemia occurring not unfrequently as a result of mechanical impediments
to the circulation in the pelvic veins and the vena cava.   It is commonly
complicated with hyperaemia of  the neighboring pelvic viscera, of the
rectum, the uterus, and the vagina ; it gives rise to a more copious secre-
tion of mucus in the bladder, to hypertrophy of the mucous membrane,
and is followed by a permanent dilatation of the vessels, and habitual
congestion.   The condition  accompanying stases in the hemorrhoidal
vessels of the rectum, in the shape of vesical hemorrhoids, is one of this
nature.
  Extravasation or apoplexy of the vesical membranes, and hemorrhage
into the cavity of the bladder, as  a consequence of hyperaemia, is a very
rare occurrence.  Even in those  rare cases it is always limited to a few
small spots, and they must be carefully distinguished from the dark-red
suffusions of  the vesical mucous  membrane, into which the  hyperaemic
condition which is# followed  by secondary exudative processes and gan-
grene frequently degenerates.
  2. Inflammation,  a.  Catarrhal inflammation.—This  occurs in the
acute form, but more frequently as a chronic affection; it is commonly
presented to the morbid anatomist in the latter shape.
  Both generally offer  the symptoms common to catarrhal inflammations.
Relatively  to the chronic form, we have the following observations to
make:
  It may be developed gradually in consequence of repeated attacks of
acute inflammation, or  be left as a  residuary affection  after the incom-
plete cure of the latter; or, as is very frequently the case, catarrhal in-
flammation  results from an extension of gonorrhoeal catarrh  to  the
bladder.  It may also be induced by the continued irritation of long-
retained and decomposed urine, as is the case when the discharge of the
urine is impeded; or lastly, by the irritation arising from calculi.
  It offers various degrees; from a pale circumscribed  redness  occa-
sionally  surrounding   the crypts only,  slight opacity and  thickening, 
URINARY  BLADDER.
173
increase of villosity and secretion of a grayish-white liquid mucus, to a
dark reddish-brown, slaty or bluish-black discoloration, accompanied by
considerable  spongy tumefaction, and the secretion  of mucus, which is
partly vitreous and clotted, partly yellow and  puriform (blennorrhoea).
The longer the disease lasts, the more the mucous membrane, from its
increased irritability and from the permanently increased innervation of
the muscular coat, becomes hypertrophied; the cavity of the bladder is
diminished in consequence, and if this condition attains a certain point,
paralysis of the muscular fibres and  consequent  dilatation of the bladder
ensue.
  In this secondary condition, after the  affection has lasted a considera-
ble period, a  rapid  exacerbation  of the chronic  catarrh  is  frequently
brought on by the irritation exerted upon the vesical mucous membrane
by the accumulation of decomposed alkaline  urine.   The inflammation
speedily attains a high degree, and terminates in exudation, fusion of the
mucous tissue, suppuration, and gangrene.
  Under these circumstances the bladder is found dilated, and filled with
decomposed,  intensely alkaline urine, mixed up with  blood of a  brown
color, viscid mucus and pus, sanies, lymph, and  detached portions of mu-
cous tissue in the shape of  discolored flocculi or larger patches.  From
this liquid, which offers a pungent ammoniacal  odor, a soft, pulverulent,
mealy sediment,  consisting  of calculous matter  bound together by lym-
phatic exudation, is deposited upon the  internal surface of the bladder.
The parts themselves are discolored, and present a dark  reddish-brown,
greenish-gray, or bluish-black hue.   The  mucous membrane, when pre-
senting a  dark-red color,  appears spongy, softened, and  pultaceous, is
easily detached  and bleeds;  when  chocolate-colored or greenish it is
found purulent,  infiltrated with sanious  matter,  or converted  into a
friable flocculent tissue, which is traversed by the urinary sediment;  or
if the process of solution is completed, and the mucous membrane has
become detached, the  surface of the cellular  and muscular  coats is ex-
posed in larger or smaller sinuous patches, appears frayed and pulpy, in-
filtrated with purulent sanies, discolored, softened, and friable.   Finally,
the muscular coat is involved in the suppurative  and gangrenous destruc-
tion, and  general peritonitis  ensues; or even  before this  takes place
sinuses are formed between the vesical  membranes, the parietes of the
bladder are eaten through, and present a cribriform appearance, and the
urine exudes into the surrounding cellular tissue and into the peritoneal
cavity.  The bladder is converted  into a paralyzed sac, the coats  of
which are thickened, though they yield  on slight pressure, they are dis-
colored, and  infiltrated with pus and sanies.
   The disease commonly proves fatal, either directly or by extension  of
inflammation to the ureters and kidneys.
   In other cases the disease has slight exacerbations from time to time,
being  limited to a more or less circumscribed  spot, which undergoes a
slower process of suppuration, and at last becomes perforated.  If, under
such circumstances, the tissues external  to the bladder have  become the
seat of inflammatory action previous to  the occurrence of perforation, a
diffuse extravasation of urine is prevented in one direction by inflamma-
tory condensation of cellular tissue—in  another, by free peritoneal  exu- 
174
ABNORMITIES  OF THE
 dation and agglutination to an adjoining organ.   The circumscribed sup-
 puration progresses slowly, and induces fistulous destruction of the tissues,
 and communications between the bladder and the external surface of the
 body, or with other holloAV organs.
   Catarrh of the bladder is of importance, under all circumstances, from
 its extension to the ureters ; and, in bad  cases, from its complication with
 renal inflammation.   It may also extend to the seminal ducts.
   A very important variety of vesical inflammation is that developed in
 the course of paraplegia; it generally passes into gangrene, and  termi-
 nates fataily.  The mucous membrane becomes the seat of extensive con-
 gestion and suffusion, which spread to the  submucous cellular tissue and
 the muscular layer; the bladder assumes a dark-red hue, is friable, dilated,
 and filled with urine ; or it is empty and  collapsed, and the mucous mem-
 brane is then partly invested with a coat of ill-looking lymph, partly in-
 filtrated with pus, partly fused into  a pulpy sanious  tissue.   The mus-
 cular fasciculi are pallid, ash-colored, and friable, and the cellular tissue
 is infiltrated with pus and sanies.  The cavity of the bladder contains a
 sanguineous, dirty brown, or chocolate-colored urine, of a pungent ammo-
 niacal odor; this is mixed up with the various products of the process,
 and deposits a white,  soft, pulverulent sediment.
   This  affection presents an extremely asthenic character, and although
 we are ready to  admit that in many cases it originates, together with the
 concurrent inflammation of the kidneys,  in paralysis, we consider that in
 others the irritation produced by the alkaline urine stagnating in  the
 bladder, is to be viewed as the chief or as a collateral cause.
   b. Exudative processes.—Primary  croup of the vesical mucous mem-
 brane is extremely rare;  but secondary exudative processes are  by no
 means as unusual as is commonly thought.   The  latter  occur during the
 course  of  exanthematic  diseases, especially of scarlatina and variola,
 during  typhus as a symptom of an  anomaly and  degeneration of  the
 typhous process, in consequence  of absorption of pus in the blood, and
 associated with exudative processes in other mucous membranes.
 ^ The affection gives rise to a more  or  less coagulable  fibrinous exuda-
 tion of varying thickness, or to a viscid,  gelatinous, discolored,  purulent,
 or sanious product; it rarely involves the entire bladder, or even a large
 portion  of  it, but is generally limited to round spots or  striae.  The mu-
 cous membrane presents the  most various degrees of injection and red-
 ness, varying from an almost imperceptible change to complete saturation
 of some portions, with considerable thickening and  tumefaction, and an
induration proportionate to the coagulability of the deposit.  According to
 the character of  the process, the diseased  tissue becomes softened and
 converted into a pale  or dark-red, reddish-brown pulp,  or a gelatinous
purulent, or sanious mass; the local  process not unfrequently assumes
 a gangrenous character, and the tissues  are  then resolved into a  putre-
 scent sanies, or become detached in the shape of an eschar.
   As the exuded matter coagulates, it not unfrequently takes up urinary
 sediments,  or these are subsequently deposited, and  give  rise  to an
incrusted appearance of the coagula or of the bladder.
   We see the typhous process occurring in  the vesical mucous membrane
under various forms: 
URINARY  BLADDER.
175
   a. It is rarely presented in the genuine shape, i. e. characterized by a
product  resembling that formed in  the intestinal  follicles  and in the
mesenteric glands.
   P. It is frequently met with as a degenerate exudative process in the
shape of scattered, insulated, and soft exudations.
   y. It is seen degenerated to an exudative  process resembling a gan-
grenous eschar.  Opportunities of observing the complete metamorphosis
of  the products and their subjacent  strata, in  the  shape of softeninc,
fusion, and separation, are but rarely offered, as the  general disease com-
monly proves fatal prior to these events.
   c. Pustular inflammation.—We advert to the rare formation of vario-
lous pustules upon the authority of other observers.   We have ourselves
not  seen  pustules  in the bladder, even  in cases in which the urethral
mucous membrane was intensely  affected by the variolous disease.
   We may at the same time mention the occurrence of small millet-seed
vesicles containing a clear serosity, and resembling a miliary eruption ;
they accompany catarrhal inflammation and slight exudative processes  in
the vesical, in the same manner as in other mucous  membranes, and are
noticed chiefly at the fundus and neck of the bladder.   It. is also an in-
teresting fact that we have found them in many cases of Asiatic cholera,
accompanied by painful dysuria, for which alkaline fomentations afforded
considerable  relief.
   d. Pericystitis.—We have already alluded to the  more or less diffused
inflammation of the cellular tissue surrounding the bladder, which super-
venes upon intense inflammation of the muscular coat and suppuration  of
the bladder (vide p. 173), or is the result  of infiltration of  urine  after
accidental or intentional wounds of the bladder, of ulcerative perforation,
and of an extension of inflammation from adjoining cellular structures;
but we have  besides these a spontaneous  inflammation of the cellular
tissue surrounding the bladder, which is designated as pericystitis.  Like
the inflammatory, suppurative, and gangrenous processes of the subcu-
taneous cellular tissue, or of the  cellular tissue surrounding  the caecum
or rectum, it may be idiopathic, though it is more frequently a secondary
process; it is to  be considered as a localization of  pyaemia, which was
either spontaneous or dependent upon an absorption  of pus, or of a dege-
nerate typhous  or anomalous  exanthematic process.   It spreads  with
facility through the cellular tissue of the pelvis, to the cellular septum of
the rectum, to the anus, and into  the scrotum; it attacks the submucous
tissue of the  bladder, and having passed into  suppuration and necrosis,
causes an exfoliation of the mucous  membrane and perforation of the
vesical parietes.
   The affection is sometimes of a chronic nature, and then gives rise to
induration, callosity, and  rigidity of the bladder.
   3.  Gangrene of the bladder.—Gangrene is the result of intense inflam-
mation, brought on by the contact or imbibition of anomalous urine in the
affected tissues, in which cases  it assumes the appearance of sphacelous
fusion (vide p. 173); or it results from contusion, and  then we find an
eschar formed (vide p. 174),
   4. Softening.—Besides the fusion  of the mucous membrane accom-
panying  the  exudative process, we have but once observed a gelatinous 
176
ABNORMITIES  OF THE
softening  of the vesical  mucous membrane.   It  occurred in a case of
typhus which had  reached the ulcerative stage, and the bladder was
found to contain a large quantity (three pounds) of putrescent urine. _
   5. Adventitious growths.—a. We have never observed the formation
of cysts between the coats of the bladder, or  in  its  mucous  membrane,
though from their occurrence in the  ureters, pelvis, and  calices (vide p.
167), we are not inclined to dispute the  possibility of the former.  We
have to remark that the  accounts of a discharge  of hydatids or acepha-
locysts from the bladder for the most part  depend  upon a descent of
these growths from the kidneys, or from other organs (e. g. the liver),
that have formed adhesions with  the urinary passages, to the bladder,
from which they are eliminated.
   b. Tubercle.—Tubercle  of the vesical mucous membrane is a very
rare occurrence, and is not even always found as a complication of tu-
bercular affection of the  urinary apparatus, which, as  we have already
seen, is combined  with  and results from tuberculosis  of  the  sexual
organs.   When it presents itself  on the vesical mucous membrane, it is
commonly also associated with tubercle of  the urethra and prostate
gland.
   It assumes the form of discrete  granulation  only, and is deposited,
with more or less reaction and vascularity, under the mucous membrane;
it becomes softened Avith  greater or  less  rapidity, and after perforating
the mucous  membrane Avithin  a  vascular area, leaves a small circular
ulcer.  According to our observations, and owing probably to the rapid
development of the tubercular disease in the other segments of this and
the sexual system, as well as to the high degree of the universal cachexia,
secondary tubercular deposition and secondary enlargement of the  tu-
bercular ulcer in the bladder, are found to be very unusual.   The cervix
and fundus of the bladder are the main seat of tubercle ; we sometimes
however  notice that  the bladder is involved in secondary tubercular
ulceration by an extension of the disease from the prostate gland.
   c. Carcinoma.—The bladder is either attacked primarily by cancer,
or the disease  is consecutive, having  spread from  neighboring organs,
especially the uterus, the vagina,  and the rectum.   The latter is by far
the more common case.
   We have  observed the following varieties of cancer :
   a. Fibrous cancer occurs but rarely in the shape of cancerous degene-
ration  of  the vesical  membranes  with thickening, cartilaginous indura-
tion, and the characteristic metamorphosis of the muscular layer; we
have seen it spread over large surfaces, at the side of  the bladder, both
upwards and downwards, accompanied by carcinomatous degeneration of
the female urethra.
   /?. Medullary cancer occurs in the shape of nodulated morbid growths
between  the coats of the bladder, and is  commonly associated with
cancer in the adjoining sexual organs of the female, and with cancer of
the rectum.   It perforates the mucous membrane, and occasionally gives
rise to a characteristic carcinomatous ulcer with raised edges.
   y. The most frequent form of cancer occurring in the bladder presents
the appearance of  soft, furred, cauliflower-like, vascular, and generally
bluish-red vegetations, which bleed  on the slightest touch, and are at- 
THE  URETHRA.
177
tached by a rounded flattened peduncle ;  they arise  from the mucous
membrane and the  submucous cellular tissue  with  delicate fibres, and
develope  a very fine membranous tissue, within which a whitish or red-
dish -Avhite, creamy or medullary (encephaloid) mass is formed.  They are
either isolated or grouped together, and at last coalesce so as to form a
very large, loose, fissured,  succulent, globular  mass  (fungus), which fills
out the bladder in proportion as the latter becomes hypertrophied and
contracted, in consequence of the permanent  irritation.   They  chiefly
occupy the neck  and fundus, the trigonum and the parts near the ure-
thral orifices ; they are sometimes spread over the entire  inner surface
of the bladder, but  they generally make their first appearance at the
aboAre-named spots, and  it is there  too that the large fungoid growths
are found.  Of several cases we  may mention one in  which these vege-
tations occupied  and  nearly filled the cavity  of  a  diverticulum of the
size of a duck's egg, which descended from the fundus of the bladder to
the rectum and perineum.
   The more they are developed, the more they  are  liable to produce
considerable hemorrhage from their extreme  vascularity; with conse-
quent cachexia  and exhaustion; they  are occasionally found  inflamed,
covered, and interlaced with lymphatic exudation, and gangrenous.
   This variety of cancer is  frequently complicated  with cancer in other
organs ;  it is especially allied  to the cauliflower excrescences  occurring
upon anomalous serous and fibro-serous membranes, and  upon the inner
surface of the compound cystoidea or of the peripheral follicles  of areolar
cancer that have been converted into large sacs  ; as also to erectile tumors
or epithelial formations  on other mucous membranes.
             SECT. IV.—ABNORMITIES OF THE URETHRA.

  § 1. Befective Bevelopment.—The  urethra is  absent  in  those  rare
cases in which the entire uropoietic system is wanting, as also in those
in which the bladder is  deficient;  it is  also wanting  in  those cases in
which there is a partial deficiency of the bladder,  as in cases of fissure,
of ectrophy in  the female sex, and of cloacal formation.  The urethra
may be imperfectly developed, presenting on the upper (epispadiasis) or
lower (hypospadiasis) surface of the penis, a fissure which  extends either
along its entire length,  or  only to a  short distance from the external
orifice; fissure of the entire dorsal surface of the penis occurs as a com-
plication of eversion of  the bladder, that  of the  inferior surface  with
fissure of the scrotum.  The latter malformation causes  a resemblance
to the vagina.   In other cases a portion  of the urethra is deficient, and
the latter then terminates in a cul-de-sac, placed at a greater or less
distance from the usual point of the orifice in the  glans penis ;  total ab-
sence of the urethra equally gives rise to an imperforate penis.
  The urethra  may, in consequence of a congenital arrest of develop-
ment,  not  open externally, but  communicate with the  cavity of the
rectum, or  in  the  female sex with the  vagina;  or vice  versa, it  may
receive the rectum or vagina at the  lower or posterior portion of  its
parietes.
  VOL. n.                          12 
178
ABNORMITIES  OF
  § 2. Beviations of Size.—They affect, with exception of congenital
shortness of the urethra, its calibre  only.   We find a  more or less di-
lated or contracted condition of the urethra occurring in both sexes as
a congenital anomaly, and affecting its entire extent or small portions
only ; it is of especial importance in the male sex.
  Dilatations  as well as  contractions  of the urethra, the latter  being
particularly frequent and important, occur as acquired conditions.
  Dilatation affects the entire canal uniformly or detached spots only;
this depends upon the locality of a  mechanical impediment, and upon
the extensibility of various portions of the urethra.   The pars membra-
nacea of the male urethra is liable  to the largest fusiform and pouchy
dilatations; a uniform dilatation of the entire canal is often brought on
by the continued use of bougies.
  Contractions of the urethra originate in primary, but more frequently
in secondary, textural changes of the urethral mucous membrane of the
corpus cavernosum  and its fibrous sheath, and we shall have to examine
them more  carefully when speaking of urethral inflammation and its con-
sequences.
  Contractions of the urethra are  also brought on in either sex by the
pressure of morbid growths, in man  by the enlarged prostate, in  the
female by neighboring organs that have been dislocated, e. g. the uterus,
the prolapsed vagina, &c.  The passage of the urethra may also be more
or less permanently or dangerously narrowed or closed up by products
of its own mucous  membrane, as well as that of the bladder,  e. g. a
mucous plug,  croupy exudation, renal  and vesical  calculi,  acephalo-
cysts, &c.

  § 3. Beviations of Birection.—Among these we reckon the serpen-
tine,  angular  or inflected,  and variously altered  course  given to  the
urethra by voluminous herniae in either sex,  by large morbid growths in
the vicinity, by the dislocation of neighboring organs (the uterus) in the
female, and especially by the enlarged  prostate in man; the latter causes
a contraction of the  urethra, and pushes it  aside, or divides it into  two
passages, which diverge in the direction of the bladder.
  Both the pressure which the urethra suffers, as well as the anomalous
direction, and  particularly the inflection induced, diminish the  calibre
of the urethra at various points.

  §t 4. Solutions of Continuity.—We enumerate under this head, wounds
of the urethra,  contusions and rupture  brought on  by a concussion or
fall, particularly upon the perineum ;  rupture produced by the passage
of large angular  calculi, perforations brought on by rude efforts at
catheterization,  and ulcerative  destruction.  In all these cases incom-
plete recovery very often takes place, leaving urinary fistulae of vary-
ing extent, length, direction, and course.

  § 5. Biseases of the Tissues.
  1.  Inflammation,  a.  Catarrhal  inflammation.—It commonly com-
mences with a more or less acute or inflammatory stage, and subsequently
passes into a protracted or chronic (blennorrhoic) stage.   It results from 
THE  URETHRA.
179
chemical or mechanical irritation by substances that have been intro-
duced from without, or it  may be developed spontaneously in children
from a scrofulous, or in aged people from a gouty diathesis, and in either
it may be connected with impetigo ;' though it has its  origin most fre-
quently in gonorrhoeal contagion (gonorrhoeal catarrh).
  We find the anatomical characters  to be those belonging to catarrh
generally ; in the acute stage there is, according to  the violence of the
process, redness, injection, tumefaction of the urethral mucous membrane,
or secretion of puriform mucus ; in the  chronic stage there is  tumefac-
tion of the mucous membrane, enlargement of the follicles, relaxation of
the sinuses, and a white  or colorless  secretion.   The inflammation is
either uniformly diffused over the urethra, or is  limited to one  or  more
spots.   The latter is especially the case  in  genuine gonorrhoea of the
male urethra; we here find not only the navicular fossa, but every point
as far as the prostatic portion, and especially the vicinity of the bulb of
the urethra, liable to become the seat of the disease.   When the gonor-
rhoea is very violent and  obstinate, a  small tubercular swelling, which
results from the deposition of fibrinous matter  in the  spongy tissue of
the urethra, is found at these points of the  urethra.   This  subject has
not hitherto received the attention it deserves, either in regard to gonor-
rhoea itself, or in reference to the pathology of stricture consequent upon
gonorrhoea, and to the gonorrhoeal ulcer of the urethra.
   The terminations and consequences  of gonorrhoea are various.   The
most common result, which is caused by great violence of the affection,
by improper dietetic and therapeutic treatment,  and by repeated attacks,
is  condensation and hypertrophy of the submucous tissue, fusion of the
latter with the mucous  membrane, and conversion of the corpus caver-
nosum into a white, resistant, fibrous, cartilaginous  tissue.   The entire
urethra sometimes undergoes this metamorphosis, subsequent to repeated
and mismanaged attacks of gonorrhoea,  but more  commonly detached
portions only are affected,  and this gives rise to partial contraction or
stricture.
   Stricture of the urethra  occurs in various shapes: the urethra is some-
times contracted  to  the extent of several lines, the parietes presenting
a cartilaginous appearance, and the lining membrane being either smooth
or having nodulated projections, or longitudinal folds ; sometimes the
stricture forms a  rounded protuberance  or  an  angular band encircling
the entire canal  or only surrounding a portion of the circumference; at
others, again, it appears in  the  shape of an irregular cicatrix, which
causes the surrounding mucous membrane to be puckered up.
   The strictures may be solitary, or  after a recurrence of gonorrhoeal
attacks, there may be two, three, four,  and more.   Their seat corre-
sponds  to  the seat of the  previous inflammation.   We have  a unique
preparation in the museum of Vienna, of a urethra of a man who had
repeatedly been affected with gonorrhoea; it presents numerous  cartila-
ginous protuberances from  the size of a millet-seed to  that of  a pea, in
part coalescing and scattered over the inner  surface, as far back as the
bulb, leaving the passage however of adequate dimensions.
1 [See note, p. 22.—Ed.] 
180
ABNORMITIES  OF
  The degree attained by the stricture varies;  Ave not unfrequently find
it so excessive, that the contracted part scarcely permits the  passage of
the finest bristle.
  The essential character of stricture consists in the same alterations^ of
this  submucous  and  mucous tissue which  we  observe   accompanying
and  following violent inflammation  of the mucous membranes, Avhen
it involves  the submucous cellular tissue ; it does not bear any specific
character.   The inflammation  attacks  the spongy substances of the
urethra at those spots at  which the diseased action was  most deve-
loped, and gives rise to a deposit of the fibrinous matter  in its meshes,
which induces the  above-mentioned swellings in  the  urethra.  If reso-
lution does not ensue this product remains, and the corpus cavernosum is
converted above it into a wheal,  varying in extent, shape,  and thickness,
and  consisting of fibrous and fibroid tissue; this is the more liable to in-
duce a narrowing of the urethra, as it possesses a great tendency to con-
tract, and the liability increases  in proportion as the sound layer of the
corpus cavernosum diminishes.   The stricture is most considerable when
the corpus cavernosum is involved throughout its entire thickness.  It is
evident that when the metamorphosis affects the innermost layer of  the
corpus cavernosum only, the gonorrhoea  may be followed by dilatation
of the urethra, and we actually find this to be the case in violent though
diffused gonorrhoea.
  The stricture, consequently, consists of the corpus callosum urethrae,
which is converted into a fibroid  callus with which the mucous membrane,
including its epithelial and submucous layer, has become  identified.   It
is in no way related to cancer, and particularly not to so-called scirrhus.
However, mechanical irritation frequently brings on excoriation, inflam-
mation of the tissue, and  ulceration,  which  in favorable  cases  may  be
put a stop to after the passage of the urethra  has been  re-established,
though it often involves the deeper parts, destroys the urethra, and in-
duces urinary fistulae.
  Strictures maintain a tendency in the urethral mucous membrane to
inflammatory attacks, which gradually extend to the bladder, the urinary
passages, and the seminal ducts.  They also lead to a dilatation of the
urethra beyond the contracted part, to dilatation and hypertrophy of the
bladder, and dilatation of the ureters.
  Those excrescences which are termed warts by medical practitioners,
and  which are  probably polypous or  condylomatous groAvths of the
urethral mucous membrane, and which are said to be particularly liable
to accompany stricture, are another  consequence of gonorrhoea.   We
have observed them very rarely.
  Lastly, we find gonorrhoeal inflammation degenerating into ulceration,
causing the gonorrhoeal ulcer, which has not been as yet  sufficiently in-
vestigated in the dead subject, and which  not unfrequently gives rise to
very fine capillary fistulae.
  True polypi, particularly of the female urethra, probably occur as a
consequence of repeated and tedious  catarrhal affections.   I have found
them in one preparation in the prostatic portion of the male urethra.
  b. Exudative processes.—In very rare  cases we find primary croup oc-
curring on the urethral mucous membranes; it induces a  circumscribed 
THE  URETHRA.
181
or a tubular exudation, according to the  intensity of the  process, and
occurs chiefly in children.
   In the^ course of hectic fever, brought on by suppuration in the vicinity,
we occasionally see more or less numerous aphthous exudations and ero-
sions on the urethral mucous membrane.
   c. Pustular inflammation.—We frequently observe variolous pustules
in the  urethra, when the disease is very intense on the general tegumen-
tary surface.   As in other mucous membranes, it is accompanied by an
exudative process  of varying intensity.
   2.  Ulcerative processes.—Besides the gonorrhoeal ulcer, the ulcerating
stricture and the ulcerative processes, with which the urethra is attacked
from without (the  prostate), and  to which it is more or less exposed in
conjunction with the penis, we have to notice the primary syphilitic ulcer
—chancre of the urethra.   Cicatrices left by ulceration, and especially
by the last variety, must  be carefully distinguished from gonorrhoeal
stricture, though this is rendered extremely difficult, as the cicatrix almost
invariably induces stricture.
   3. Adventitious formations.—In addition to the fibroid tissues occur-
ring after gonorrhoeal inflammation, and especially in strictures, to  the
problematic carunculae or warts of the urethra,  we find that tubercle and
tubercular ulceration  (Tuberculosis urethras) are formed in the urethra,
though only in conjunction Avith tuberculosis of the entire urinary appa-
ratus.    The urethra is also attacked by cancer and cancerous ulceration;
in the male sex this accompanies, or is the consequence of, carcinoma of
the  penis,  and especially of the glans.

   § 6.  Anomalous Contents of the Urinary Passages.—The anomalous
contents of the urinary passages  are  very various, and may be classified
as follows:
   1. The  products  of the  organic affections of the secretory as well as
the efferent apparatus;  they are the more intimately mixed  with the
urine,  the  nearer  the  point of their formation  is  to the place where the
latter  is secreted, and the  greater their capability of suspension  and
their solubility.
   2. The deviations which the urine presents,  independent of the first-
mentioned admixtures, whether accompanied by a demonstrable disease
of the renal texture, or  unassociated with any traces of structural  dis-
ease :  they result  from an anomaly in the vegetative  sphere, and espe-
cially  in the blood;  they may also occur as a passing effect of certain
indulgences, and they  relate to the quantity and quality, and particularly
to the physical characters of the urine.
   In reference to  1, we  have  to notice :
   a. The blood and certain of its component parts.   The former (haema-
turia)  is found in  the  urinary passages, to a larger or smaller amount,
in the shape of rounded  or cylindrical coagula  of varying consistency, or
mixed with the urine in a fluid condition.   It appears in  consequence of
various injuries involving the kidneys and  the urinary apparatus, pro-
duced by means of cutting instruments, concretions, ruptures, apoplexy
of the kidney, the bursting of an aneurism into the urinary passages, or
of varicose veins  into the bladder, ulcerative  corrosion  of a vessel, or 
182
ABNORMITIES OF
bleeding carcinomatous growths in the urinary organs.  It results from
hyperaemia, nephritis, Bright's disease, hemorrhagic inflammation of the
passages, and from disorganization of the blood.   Sometimes it is not
true blood—blood-globules—but mere haematosine, which passes into the
urine from the serum in the kidneys.  We also find other constituents of
the blood, such as albumen and fibrine, in the urine.
  Albumen is discovered in the course of numerous diseases both  accom-
panied by and unassociated with renal disease.   In many acute diseases,
albuminous urine is secreted with an excess of lithic acid, and lithate of
ammonia.  Albumen is sometimes found with sugar in diabetic urine ; it
always  occurs in hemorrhage  into and inflammation of the urinary pas-
sages, in hyperaemia, nephritis, &c.   It is found to a large amount in
Bright's disease of the kidney, frequently mixed up with blood-globules,
or haematosine.  Its  presence is demonstrated  by milky  turbidity of
urine, by the urine foaming when air is blown into it, by coagulation of
the albumen on the application of heat, the addition of alcohol or nitric
acid, &c.
  Fibrine  is  said to have been found in  the  urine  in  some cases of
dropsy;  in the case of hemorrhage into the urinary apparatus it forms
coagula of various shapes and sizes, which are easily recognized.
  b. Exudations in the urinary passages, assuming the shape of flocculi,
laminae and tubular concretions.
  c. Grayish,  milky, vitreous, colorless, purulent yellow (blennorrhoic)
mucus, pus and sanies, may be intimately blended with the urine, caus-
ing it to be variously discolored or turbid, or forming flocculent  concre-
tions, and  loose, crummy, viscid, glutinous  sediments.  Mucus appears
in the urine as the effect of acute, but more  frequently of chronic catar-
rhal inflammation of  the urinary passages. Pus  and sanies  are the
result of suppuration of the  kidneys, with discharge of the abscess into
the urinary passages, and of suppuration,  and the formation of sanies in
the latter ;  or these fluids reach the urinary cavities  from  neighboring
organs by  ulcerated communications ; they may also be the consequence
of gangrene, tubercular or cancerous degeneration.  We also find in the
urine, besides the aboAre-mentioned  substances, epithelial lamellae, tuber-
cular matter,  elementary cells of cancer, &c.
   d. It is stated that the urine contains a substance resembling cerebral
fat, when the kidney is affected with medullary  cancer.  The immediate
condition of this occurrence  has not  as yet  been determined ; it is pro-
bably essential that the  morbid growth should have forced its way into
the urinary passages, or that  it should project into them.
   e. Ancient and modern observers have noticed that hairs are some-
times evacuated with the urine ; they may be formed  within or external
to the urinary organs.
  /. Within the most  recent  period, Curling has discovered a new ento-
zoon, the  dactylius aculeatus, in the bladder.   A very recent  case is
also given of the discharge of cysticerci with the urine;  acephalocysts
are frequently carried into the urinary passages both from the  kidneys
and from other organs, and are evacuated with the urine.
   In reference to 2, we observe that the deviations of the urine  as re-
gards  quantity, may consist in excessive or  diminished secretion • if the 
THE  URETHRA.
183
quantity found in the dead subject be  small, it is  requisite to ascertain
the evacuations that have taken place before death ; if considerable, the
obstacles to its discharge must be inquired into.  Urine presents various
anomalies as to quality,  affecting both its physical and chemical pro-
perties.
  a. The color of the  urine is either too intense,  owing to a large
amount of coloring matter, which is generally combined with lithic acid
or urea; or it is very pale, and, at  the same  time, less acid or neutral.
The urine assumes a red color from an admixture of blood or its coloring
matter; if there is at the same  time an excess of acid, it may become
reddish-brown, brownish-black, or in very rare cases, which  are probably
dependent upon an alteration in the haematosine, it  may even become
perfectly black.   Biliary matter produces a yellow, yellowish-brown,  or
even greenish discoloration.   We must finally allude to those anomalous
appearances of the urine  produced by the consumption of various sub-
stances that are rich in coloring matter, as beet-root, madder, rhubarb,
gamboge, chelidonium, indigo, ink.  The urine may at the same time
be  transparent or  turbid ; the latter,  in so far as it is independent of the
above-mentioned  foreign admixtures, is proportionate to the lithic acid
or  lithate of ammonia contained in acid, or to the phosphates in alkaline
urine.
   b.  The  odor of urine is  either more or  less powerful than  in the
normal condition; thus the pale watery urine is frequently almost with-
out smell, whereas the saturated urine of acute rheumatism or of pneu-
monia smells  very strongly.  Occasionally the urine presents the odor
of broth or of whey ; in diabetes mellitus it has a spirituous smell, owing
to  the commencement of fermentation, or its odor resembles that of de-
composed straw, of putrid matter, or  is very pungent.  Different odors
are perceived after  the  consumption of  asparagus, turpentine,  the
balsams,  leek,  assafoetida, &c.  In diabetes mellitus, the urine has a
sweet taste.
   c.  Specific gravity.—This  is either  above or below the normal stan-
dard.   It is  excessive in diabetes  mellitus,  and  very low in diabetes
insipidus.   In the chronic form of Bright's disease  it is diminished, as
the proportion of urea and of the  urinary salts  is  diminished, at  the
same time that the albumen increases; in the acute form it is not unfre-
quently increased.
   3. As regards the chemical composition of the urine, we find that the
normal constituents exist in irregular proportions, or that there are new
and unusual substances.
   a. The watery  portion of the urine is in excess in numerous affections
of the nervous system, in hysteria, in  diabetes insipidus,  and according
to  Rayer and older observers, in advanced age ; its quantity is too small
in  proportion to the solid constituents in  the saturated urine of acute
diseases, especially at the period at which critical discharges occur.
    b. The urea  does not, as was formerly believed, bear a direct relation
 to the coloring matter of the urine, a fact that has  been distinctly proved
 by Prout  in some cases of diabetes  insipidus.   It is more frequently
 morbidly  diminished, as in  diabetes mellitus, in  Bright's _ disease, and
 numerous other diseases that haAre  not  as yet been  clearly diagnosed, and
 in which, as the urea disappears, albumen is substituted. 
184
ABNORMITIES  OF
   Original deficiency of urea is to be carefully distinguished from that
 deficiency which results from its decomposition in consequence of stag-
 nation in the  urinary passages, from the  influence of mucus, purulent
 secretion, and pus.
   c.  Uric acid, either free or combined with  a base, and especially in
 the shape of urate of ammonia, is deposited in the form of small crystals,
 or of a yellow or lateritious powder.  It is increased in quantity in rheu-
 matism,  gout, and  inflammatory affections;  in hysterical urine,  in  the
 urine voided during the  cold  stage of intermittent fever, and in nume-
 rous other diseases, it is diminished in quantity.  If free acid is present
 in the urine it may be precipitated in the shape of gravel, though not
 itself in excess.
   d.  The phosphates  (phosphate of  lime, phosphate  of magnesia, and
 triple phosphate of ammonia and magnesia)  are often present in excess.
 Phosphate of lime is deposited in the absence of a free acid, and phos-
 phate  of ammonia  and  magnesia,  as  a basic  salt;  these form  the
 phosphatic sediments.   As  the  latter salt is formed in consequence of
 the development  of ammonia, it  occurs principally in  urine  containing
 much mucus,  pus, seminal fluid, and other animal  substances that  are
 easily decomposed.   The lithic acid is, at the same time, proportionally
 diminished, and the urine is neutral or alkaline.
   e. The alkaline state of the urine is of  extreme importance ; in many
 cases that have not as yet met  with a sufficient explanation, it appears
 to be the result of a morbid secretion, or it depends upon decomposition
 of the urine, and presents various degrees.   The urine in this condition
 is commonly pale and turbid.  It is particularly alkaline  in chronic in-
 flammation of the kidney, and in numerous diseases of the urinary pas-
 sages ; it is so sometimes in a slight degree, and temporarily, in Bright's
 disease.   The alkaline state of  the urine in diseases of the spinal cord,
 in paraplegia,  has attracted some attention, and  has  given rise  to  the
 question, whether this alkalescence is  the result  of a simple derangement
 of the act of secretion, i. e. whether the urine is secreted as an alkaline
 fluid; or whether an acid urine becomes  alkaline in consequence  of de-
 composition, by means of the products of coexistent cystitis or nephritis.
 The question has not  received a satisfactory reply.  Post-mortem  exa-
 minations have generally demonstrated the existence of the latter series
 of causes of alkaline urine; the examinations of the urine in living sub-
jects have been either neglected  in the class of cases that come  under
 this head, or they have but little value, on  account of the insufficient
 diagnosis of existing inflammation of the  urinary passages  and the kid-
 neys.  The only proofs  in evidence of alkaline urine being secreted by
 the kidneys, are  afforded by the vivisections of Krimer  and  others  in
 which, after the division of the  spinal cord, urine of the appearance of
 pure water was secreted;  and  by the clear neutral or  alkaline urine
 passed in hysterical or  epileptic attacks.  Rayer has found the urine
 acid in cases of recent paraplegia, unaccompanied by retention of  urine
   The following substances are rarely found as constituents of the  urine:
  a. Purpuric acid, a modification of lithic  acid, produced by the pre-
 sence of nitric acid, and  purpurates (purpurates of ammonia  and  soda)
 which are said to give a red color to the urinary sediments (Prout). 
THE  URETHRA.
185
  13. Hippuric acid (Liebig), which  has been  found in children  in the
shape of hippurate of soda, and in diabetes.
  y. Oxalic acid is, according to Prout, the result of a decomposition of
lithic acid, and occurs as oxalate of lime, in the form of  a greenish or
blackish sediment, or of gravel or calculous concretion.
  8. Benzoic, butyric, and cyanic acid, cyanurin and melanurin in blue
and black urine, xanthic oxide (Marcet), and cystin (Wollaston).
  e. Sugar, in varying proportions,  in diabetes mellitus.
  Z. Cholesterin.
  jj. Numerous medicinal substances.
  The formation of calculous concretions in the urinary organs is  a mat-
ter  of extreme importance;  it takes place within  the kidneys,  in the
pelvis and calices of the kidneys, in  the ureters, the bladder, the urethra,
the urachus, and even  externally to these passages.  The pelvis and ca-
lices of the kidney and the bladder are, however, the parts in which cal-
culi are most frequently formed.  The latter present considerable varie-
ties, both as regards their  physical properties and their chemical compo-
sition.
  aa. When the concretions are very small they are termed gravel, and
may be very numerous or few in number.   Gravel may be formed at any
part of the urinary apparatus, and even in the kidney.   The red variety
consists chiefly of lithic acid, the white of phosphates.   Calculi are larger
concretions, which again differ much as to volume and weight.   In size
they vary from that of a millet-seed to that of a goose's egg, or a fist.
  /5/5.  Vesical calculi are generally of a globular, ovate, or oval form;
they are frequently flattened so as to present a discoid  or  lenticular
shape; if two or more coexist, friction  planes  are formed giving the cal-
culi when numerous, a polyhedral shape. Large renal calculi are moulded
according to  the  form of their nidus, and assume a  branched appear-
ance.   In rare cases the calculi are hollow, forming tubular or conchoid
concretions.   Their surface is  either smooth  or  rough, angular or  fis-
sured ;  or it appears  decaying,  gnawed, granular, of a mulberry form,
or  set with sharp, prickly  projections, crystalline, &c.
  yy. The number of the  calculi present  varies;  there  are  generally
several renal  calculi, whereas vesical calculi are commonly  solitary;
however, there  are cases on  record  in which fifty,  a hundred, nay,
several hundred calculi, especially of the phosphatic variety, were found.
   Sd. In color, consistency,  and texture,  they vary  much,  and these
qualities depend upon their chemical composition.
   The  substances entering into the  chemical constitution of urinary cal-
culi are numerous; sometimes one  only form  the calculus or  predomi-
nates, at others several  are mixed  up together, or disposed in  layers.
They are not all equally frequent.
   a.  Lithic acid enters into the composition of most calculi, inasmuch as
many consist  entirely of it, many in part, and as it forms the nucleus of the
majority.  Lithic-acid calculi are commonly  of  considerable hardness,
smooth, light or dark brown, rounded, and often flattened. ^
   /3'. Lithate of ammonia and lithate  of soda  rarely enter into the com-
position of calculi.   Those consisting of the  former are yellow,  and of
a loose texture; those composed of the latter are white and chalky. 
186
ABNORMITIES OF
  y. Phosphate of lime rarely forms a calculus by itself.
  8. Phosphate of ammonia and  magnesia forms small, friable, white
calculi, that have a shining crystalline investment.
  Calculi consisting  chiefly of the two  last-named substances and car-
bonate of lime, are very frequent.   They are  white, of a loose  texture,
and often of a considerable size; they are generally formed in conse-
quence of inflammatory affections of the kidneys and  urinary passages,
which in their turn are frequently induced by the  presence of a lithic-
acid calculus, or some other foreign body, which serves as a nucleus for
the calculous deposit.
  i.  Oxalate of lime forms the mulberry-shaped, nodulated, dark-brown
or black, and very hard calculi.
  Z'. Xanthic oxide and cystine are very rare.  The latter we generally
find combined with fat, resin,  coloring  matter,  iron,  silica.   In rare
cases we also find fibrinous  coagula, in the shape of carneous or fibrous
elastic masses, entering into the formation of calculi.
  Vesical calculi are either contained free and unattached in the bladder
or are firmly grasped by the bladder, which  has become hypertrophied
in consequence of catarrhal attacks.   They are found encysted in hernial
diverticula of the bladder, or lie in saccular  expansions of the vesical
parietes, which they  form for themselves during the contractions of the
bladder; they sometimes become agglutinated to these and other parts
by means of fibrinous exudations.
  Urinary calculi offer mechanical obstacles  to the conduction  and  dis-
charge of the urine,  and give rise to inflammations of the kidneys  and
urinary passages, proportionate to the size of the calculi, and the rough-
ness and irregularity of their surface.   They  are sometimes,  even when
of considerable  magnitude, discharged by the natural passages, espe-
cially in the female ; still  they more  commonly cause severe injuries of
the urinary channels, rupture of the  urethra, &c.  At other times they
make their way by inflammation and suppuration into neighboring cavi-
ties, as into the rectum, the vagina, or into abscesses, and from  these by
unnatural passages outwards.
   In very rare cases we find urinary calculi enclosed in cartilaginous
capsules external to  the urinary passages, having either forced their way
out of the latter by rupture or ulcerative perforation, or  haA'ing been
formed at  the spot  where they are discovered, in urine that has been
previously extravasated.

          Appendix.—Biseases of the Suprarenal Capsules.

   The suprarenal capsules are occasionally  deficient, especially when
there is a  deficiency in other organs  also.  They are not always absent
in acephalous monstrosities; and as their absence generally involves the
absence  of numerous other organs, the fact suggests no distinct inter-
pretation as to their functions.   They are, moreover, generally present
when one kidney is absent, and this proves that they are perfectly inde-
pendent of the kidneys and the sexual  organs (Meckel); their diseases
place them in a more distinct relation with the lymphatic glands. 
THE  URETHRA.
187
  The fusion which often occurs  in the kidneys is not found to take
place in the suprarenal capsules.
  Accessory suprarenal capsules, indicating an apparent excess of de-
velopment, are of frequent occurrence.  Several flattened acessory su-
prarenal capsules are then found in the renal and solar plexuses, and on
the ganglion of the latter, varying in size from a millet- or hemp-seed to
that of a pea.
  They are occasionally of great magnitude, a circumstance which calls
their foetal condition to mind, though it may result from morbid  affec-
tions.  On the other hand they may be small; and this may equally be
the consequence of a congenital or an acquired  anomaly.  A reduction
of size occurs in the shape of marasmus in advanced age, or at an earlier
period of life; the organ shrivels up, becomes tough  and coriaceous, its
cortical substance assumes a dirty yellow color, its vascular medullary
substance is obliterated; or in some cases it becomes friable, of the color
of the lees of wine, or  of  a rusty brown, so as to resemble the spleen of
old  persons.  The atrophy  may also  be the consequence of textural
changes, appearing after inflammation in the shape of induration or obli-
teration.
   The form of the suprarenal capsules is subject to various unimportant
deviations ; in reference to their  position we have  to remark, that they
do  not follow the congenital dislocations of  the kidneys, but in  these
cases invariably retain their normal position.
   Their textural diseases have  hitherto met with little consideration.
Hemorrhage not unfrequently occurs in them, on  account of the vascu-
larity of their  medullary substance.   The suprarenal capsule is found
distended in proportion to the amount of extravasation  caused by the
rupture of a vein; and according to the period that has elapsed since the
occurrence of the hemorrhage, we find the blood, more or less discolored
and changed in constitution, enclosed within the cortical substance, which
has  become pale and atrophied, and  is finally converted into a fibroid
layer.
  We scarcely ever  have an opportunity of  observing inflammation of
the suprarenal  capsules, except in its terminal stages, suppuration  and
induration.   Some observers have found the suprarenal capsules con-
verted into purulent  pouches  in the new-born infant, and even in the
foetus (Andral).
   The morbid growths not unfrequently seen, are:  tubercle and cancer-
ous  degeneration;  both, and  particularly the  latter, are  found com-
plicated with similar  affections of other organs, and especially of the
lymphatic glands.
  Tubercle commonly appears deposited in  the  suprarenal  capsules in
large masses, and either  fuses into pus enclosed in a callous sac, or is
converted into a  chalky concretion, invested by a fibroid tissue, in which
all traces of the proper tissue of the organ have disappeared.
   Cancer commonly appears in the form of medullary carcinoma, which
very frequently involves the neighboring glands of the lumbar plexus,
and the kidney, and causes a considerable enlargement of the suprarenal
capsule.   Hemorrhage occasionally takes place within the parenchyma 
188
ABNORMITIES,  ETC.
of the cancerous  growth, and causes it to be broken down into a choco-
late-colored pulp.
  It frequently happens that the suprarenal capsules become adherent
to the kidneys in consequence of inflammation, or of other diseases asso-
ciated with inflammatory reaction.  A much rarer, though very interest-
ing, occurrence is congenital union of the two organs, in which case  one
tunica albuginea invests the two, and the concave surface of the supra-
renal capsule adheres to the  kidney by means of short, tense, vascular,
cellular tissue. 
          PART  III.




ABNORMITIES OF THE SEXUAL ORGANS. 
» 
CHAPTER I.
     ON ABNORMITIES OF THE SEXUAL ORGANS GENERALLY.

  The sexual organs  are  occasionally entirely absent;  a  defect that is
commonly associated  with imperfect  development  of  other parts, and
especially with acephalia ; a more or less important section of the appa-
ratus is often defective, and  one of the symmetrical organs, or one half
of those organs which unite in the mesial line, may be absent; or again,
one of these organs, or halves of organs, may be imperfectly developed,
and its cavity contracted  or  closed  up; or the apparatus may be  com-
plete in its  different  constituent portions and not have been duly  deve-
loped,  remaining permanently small and inefficient, so that the individual
presents no  sexual character.
  Another defect of the sexual organs assumes the form of fissure, which
is an arrest  of  various stages of embryonic development.   The highest
degree of this malformation is presented in the cloaca, which is to be ex-
plained as a persistence of the original sinus urogenitalis, or an imperfect
separation of the parts that form the latter.   A lower  degree of this
species of deformity is presented in the fissured condition of the sexual
organs, in which case the foetal or female character predominates; we
allude  to the various fissures  of the uterus, of the vagina, the penis, the
urethra, or the scrotum, with or without a'residuary trace of the urogeni-
tal sinus.
  From these  latter, apparently hermaphroditic formations, which  de-
pend upon an arrest of development, those pseudo-hermaphroditic forma-
tions, which consist in an excessive development of certain portions of
the female organs of generation according to the male type, form a transi-
tion  to true hermaphrodisia, i. e.  hermaphrodisia per  excessum;  in
which  case  certain portions of the  sexual apparatus of an opposite  sex
are superadded.
  In addition to the  just-mentioned  excess of formation we meet with
another form in the shape of a repetition of certain sections  of the appa-
ratus, which may either present itself as excessive development of volume,
or as precocity.
  Besides congenital  deviations of size, we find many that are acquired;
in addition to those varieties which depend upon textural diseases, and
particularly upon adventitious  growths, they occur in  the shape of  hy-
pertrophy and  atrophy.   The uterus  in the female, the prostate in  the
male sex, are particularly liable to be affected by the former ; the latter,
independently of the  process of involution (tabes senilis), which more or 
192
ABNORMITIES  OF  THE  TESTES
less uniformly involves  the  generative  system,  especially attacks the
testes and the ovaries, and in a second degree the uterus.
  The sexual organs are subject  to  numerous congenital deviations as
to form; the uterus and its cavity are  peculiarly liable  in  the female,
the prostate in the male sex, to acquired malformations.
  The position of the external sexual  organs depends upon the congenital
or acquired degreee of inclination of the  pelvis, and other malformations.
The most important  congenital deviation  of position of single organs
affects the testes ; the uterus  presents  very important acquired irregu-
larities of this class.
  Diseases of the tissues are peculiarly  frequent in the female organs of
generation ; and among them the adventitious growths are most remark-
able.   We shall have  occasion  to advert in detail to  many points of in-
terest, relative  to the morbid growths occurring in the sexual organs of
either  sex.
                         CHAPTER  II.

      ABNORMITIES OF THE MALE ORGANS OF  GENERATION.

          SECTION I.—THE TESTES AND  VASA DEFERENTIA.

  § 1. Befect and Excess of Formation.—The testes are absent when
the entire sexual apparatus is absent; sometimes they are wanting when
the other parts are defectively developed, or are  represented by a few
coils of a seminal duct:  lastly they may be in existence, but of small
size, and incapable of further growth.   In  this  case the  epididymis  is
particularly small, its ligament elongated, and the entire organ apparently
broken up.  This  is very commonly the  case when the testes remain  in
the abdominal cavity or in the inguinal canal, and there is an apparent
absence of testicles (cryptorchis).
   The vas deferens may present a malformation, and after diminishing
gradually, terminate blindly at some distance from the vesiculae seminales
and generally in the inguinal canal.
   Excess of development, in the shape of a  plurality of testicles, is un-
doubtedly very rare : the fact itself is not supported by sufficient proofs.

   § 2.  Beviations of Size.—Increase of size of the testicles depends upon
hyperaemia, upon inflammation and its consequences, i.  e. upon the in-
flammatory enlargement itself, and the residuary  product of  inflamma-
tion and induration upon hypertrophy of the cellulo-fibrous stroma, and
upon morbid growths and degenerations of the organ.
   Enlargements of the testicle are to be carefully distinguished from dis-
tension of the tunica vaginalis.
   Besides congenital  smallness of the testicle, dependent upon arrest of
development, we not unfrequently meet with atrophy of the testicle.   It 
AND  VASA  DEFERENTIA.
193
occurs not only in the shape of marasmus senilis, accompanied by flabby
texture of the  organ and a dirty yellow color of its tissue, but is found
at earlier periods of life as a consequence  of exhaustion, of gonorrhoeal
neuralgia of the testis, and from unexplained influences in the tropics
(Larry).  The  testicle also becomes atrophied in consequence of pressure
exerted by effusion  in the  vaginal sac, by large herniae, by exudations
within its substance, and  by morbid growths.

  § 3.  Beviations of Position.—We have to notice the foetal position of
the testicles within the abdominal cavity, or in the inguinal canal (crypt-
orchis).  It is  important  both from being commonly associated with de-
fective development  of the testicle, and on account of the doubt arising
as to the sex of the individual, as well as on account of the descent of
the testicle, which commonly occurs about the period of puberty, and the
consequent occurrence of (congenital) inguinal hernia.
  In rare cases the descending testicle does not pursue its regular course ;
it either passes under the crural  arch, or sinks into the pelvic cavity.

   § 4.  Biseases of the Tissues.
   1. Inflammation.—a.  Inflammation  of the testicle is a common occur-
rence ;  but nevertheless, rarely a subject  of cadaveric investigation.  It
may be either primary, secondary, or metastatic.
   It may also  be acute, or, as is  more  frequently the case, chronic  ; it
either attacks the entire testicle, or the epididymis, or single lobules of the
former  chiefly.  Accordingly, the tumefaction of the organ  is either uni-
form or irregular; its tissue is at first more or less reddened, injected,
and according  to the  coagulability of the inflammatory  product, either
firmer or looser than in the normal condition.
  Acute  inflammation not unfrequently passes into suppuration ;   the
chronic form more frequently ends in induration and permanent enlarge-
ment of the organ.   The orchitic abscess not unfrequently discharges ex-
ternally by one or more openings, after  inducing perforation of the tunica
albuginea, and of the agglutinated lamellae of the tunica vaginalis.   The
inflammatory product becomes more or  less organized,  and converted
into a  fibroid cartilaginous mass, and the  resulting induration induces
atrophy of the  testicle.
   b. Chronic inflammation  affecting  the  tunica albuginea,  and its  pro-
cesses, in rare cases induces considerable thickening of this fibrous sheath,
hypertrophy of the  fibro-cellular tissue within the  testicle,  enlargement
and morbid induration of the latter, and finally atrophy of its proper
tissue.
  The progress of inflammations of the  testicle would appear to be some-
times impeded, and a cure brought on, by the pressure which an effusion
into the tunica  vaginalis exerts.
  2. Morbid growths.—a. We have already found that fibroid tissue
occurs as a consequence of chronic inflammation, and its termination in
induration.
  b. The formation  of cysts is  very unusual, a fact that acquires special
interest from the frequency of their occurrence  in the ovaries.
  c. Enchondroma is equally rare.
    VOL. II.                         13 
194
ABNORMITIES OF THE
  d. An anomalous osseous substance is sometimes deA-eloped in the in-
durated testicle, i. e. in the fibroid tissue; and assumes the shape of round,
tuberculated, or tendiniform concretions.
  e. Tubercle.—Tubercle not unfrequently attacks the testicle primarily,
and its chief seat is the epididymis.   From this point it not only spreads
to the vasa deferentia,  the vesiculae seminales, the  prostate,  and  the
glands that are connected with the organs of generation generally ;  but
also to the lymphatics of the abdomen, the thorax, and even of the neck,
on the one hand, or on the other to the urinary organs, in the manner pre-
viously described (p. 161).  In the former case we  find the glands  ag-
gregated or strung together in large, shapeless, nodulated masses, and
infiltrated with cheesy tubercular matter.
  Tubercle is  developed in young subjects who are predisposed to tuber-
cular affections, in consequence of excessive or unnatural gratification of
the sexual desires.  The pathological anatomist has been unable  to  de-
monstrate its connection with gonorrhoea, or, in other words, to prove the
blennorrhoic character of the general morbid affection, as well  as of
tubercle  itself; and  we, therefore, consider the gonorrhoeal theory of
orchitic tubercle to be wanting in a most essential point.
  The affection proves fatal, either by the universal atrophy induced by
the  effusion of tubercle throughout the lymphatic  system, or by the su-
pervention of more  or less acute tubercular deposition in the urinary
organs, in the lungs, on  the peritoneum, and in the spleen.
  Orchitic tubercle generally appears in the shape of rounded nodules,
of  the size of a millet- or hemp-seed,  or  a pea, which  coalesce into
larger  masses; they scarcely  ever undergo  a  retrograde metamor-
phosis, but fuse, and  thus establish tubercular suppuration or phthisis
orchitica.  The increase in size of the  testicle varies according  to  the
number of the  individual tubercles, and more  still according to the size of
the tubercular conglomerations.  Its  surface is irregular and nodulated.
The tissue surrounding the tubercle and the tubercular abscess becomes
cartilaginous,  lardaceous, and tough.
  In the same manner as elsewhere, and especially in the lungs, we find
inflammation of the serous investment supervening  upon tubercular af-
fections ;  thus the tunica vaginalis testis is liable to  attacks of inflamma-
tion, accompanied by tuberculizing exudation of various  forms.
  Tubercle of  the testicle is of extreme interest as  contrasted with  the
immunity from tubercle  enjoyed by the ovary.
  /. Cancer.—All the varieties of cancer undoubtedly occur in the  tes-
ticle, but both according to my own observations and  those of others
medullary carcinoma is the most frequent.   It ahvays gives rise to very
extensive degeneration, is verysoft, and presents fluctuation ; sometimes
it perforates the tunica vaginalis and the skin, and is thus converted into
an  open cancerous sore.
   It generally so completely takes the place of the proper orchitic tissue
that no trace of the latter is left; still many cases occur in  which it oc-
cupies the interstices of the hypertrophied fibro-cellular stroma  of the
testicle.   It is peculiarly liable to a complication with renal cancer  and
also with medullary growths in the cellular tissue surrounding the pelvis
and the  hip-joint, with  medullary retro-peritoneal  growths, and  finally
with universal cancerous cachexia. 
V E S I C U L JE SEMINALES.
195
  The frequency of its occurrence in the testicle, especially as a primary
affection, is of interest when contrasted with the rarity of its appearance
in the ovary, and with the frequency of cysts and the allied form of areolar
cancer, in the latter.

  The yas deferens is generally attacked by disease extending to it from
the testicle, or the  vesiculae seminales ; it is  found  to  be affected by in-
duration and thickening of  its coats and ossification, which probably re-
sult from inflammation, by tubercle, and cancerous degeneration.


       Appendix.—Abnormities of the Tunica Vaginalis  Testis.

  In  consequence of  an arrest of development, the cavity of the tunica
vaginalis may remain in  communication with  the peritoneal cavity, and
thus give rise to congenital  inguinal hernia.
  All the diseases affecting the tissue of  serous membranes are found to
occur here; inflammatory affections of every degree and variety, followed
by the most various effusions, are common; and of  the sequelae, adhesion
by means  of  various tissues  of new formation, and  ossification  of the
fibroid exudations,  are not unfrequent.   Among the morbid growths we
notice the anomalous fibroid and osseous tissues in the form just mentioned,
as well as subserous, fibro-cartilaginous,  and  osteoid formations, which
we sometimes find as  free  corpuscles in the tunica vaginalis, and tubercle,
occurring especially as tubercular exudation; this must be distinguished
from  tuberculosis of the testicle, with which, however, it is often coinci-
dent.
  Dropsy of the tunica vaginalis, or hydrocele, is a common disease, oc-
casionally brought  on by varicosity and  stasis in the venous  network of
the testicle and the spermatic cord, in which case it has the character of
a passive accumulation ; sometimes it is the result of slight inflammatory
affections of the serous membrane.


        SECT.  II.—ABNORMITIES OF  THE VESICUL2E SEMINALES.

  § 1. Arrest and Excess of Bevelopment.—The vesiculae seminales are
absent when the testicles are deficient, and are more or less abortive when
the testicles are imperfectly developed.
  It is stated that they have been found increased  in number in cases in
which there were supernumerary testicles.

  § 2. Deviations of size.   Of calibre.—Under this  head we class, on
the one hand, the dilatations of the vesiculae seminales and ductus ejacu-
latorii, resulting from continued catarrhal irritation, which, according to
Lallemand, accompanies  spontaneous discharges of semen, and on the
other, the atrophy and obliteration of the vesiculae seminales, which may,
but does not necessarily,  follow removal or atrophy of the  testicle.

  § 3. Biseases of the Tissues.
  1.  Inflammation.—We not unfrequently have opportunities of observ-
ing, in the  dead  subject,  the  effects of chronic catarrh and its sequelae, 
196
ABNORMITIES OF
upon the vesiculae seminales;  they are, especially, tumefaction and re-
laxation of their  mucous membrane; secretion  of a grayish or yellow
purulent mucus (blennorrhoea), dilatation, and, finally, thickening of the
parietes.   In rare cases Ave find those portions  of the inner  surface in
which the mucous membrane has been destroyed by suppuration, covered
by a whitish or slate-colored, reticular pulp, of a cellulo-fibrous texture,
the parietes considerably  thickened and cartilaginous,  and the cavity
contracted  and obliterated.   This inflammation as rarely degenerates
into ulcerative perforation  of  the  vesiculae seminales, the formation^ of
abscesses in their  cellulo-fibrous nidus, into destruction of a neighboring
coil, or communication of two contiguous tubuli.
   Chronic catarrh occurs chiefly in advanced age,  accompanying mechani-
cal hyperaemia of  the pelvic veins, stasis, varicosity, and the formation
of phlebolithes; as a consequence of chronic vesical catarrh, as a result
of repeated gonorrhoeal catarrh of the urethra and the neck of the blad-
der, of excessive venery, and especially of masturbation.
   2. We find a Ioav state of irritation developed in a similar manner in
the cellulo-fibrous substratum of the vesiculae seminales ; this induces con-
densation and hypertrophy  in the  latter, and causes its  adhesion to the
A'esiculre seminales, which thus become fixed.

   §  4. Morbid Growths.
  1. Bony matter is  sometimes deposited in  the indurated  coats of the
vesiculae seminales, as well as in the terminal portion of the vas deferens
(ossification).
  2. Tubercle.—Tuberculosis of  the mucous membrane  of the vesiculae
seminales is not an unfrequent disease.   When seen in the  dead subject,
the disease has generally attained such a  degree that the mucous mem-
brane appears converted into a thick, yellow, cheesy, lardaceous, fissured,
purulent layer of tubercular matter, filling up and closing the passage of
the seminal vesicles, whilst the superficial layer of their coats is conside-
rably thickened, and  infiltrated with a lardaceous substance.  The exter-
nal investment occasionally becomes the seat of tubercular deposit,  and,
as this fuses, suppuration and perforation of the seminal vesicles are in-
duced.
   Tubercular disease is associated with tubercle  of the prostate, the tes-
ticle, and the lymphatic glands that belong to the  sexual apparatus, as
well as with tubercle  of the uropoietic system.    It  prevails during the
prime of life, and appears never to occur before puberty;  in this it differs
essentially from tubercular disease of the  uterus and the Fallopian tubes.
   3. Cancer  affects  the vesiculae  seminales only by  extension from
neighboring organs.

   § 5. Anomalies  of the  Contents of the  Vesiculce Seminales.__The
seminal fluid may present various irregularities ;* it is found mixed  with
a greater or less quantity of colorless, vitreous, grayish, yellow  puriform
mucus, and with pus; if the inner  surface of the vesiculae seminales has
undergone  any change of texture there may be  hemorrhagic exudation
tubercular  pus, cancerous sanies, and, lastly, calculous concretions.  The
pus  and sanies may, as in the ductus ejaculatorii, be introduced from 
THE  PROSTATE.
197
neighboring  abscesses, especially of the prostate, after perforation has
taken place.

             SECT. III.—ABNORMITIES OF THE PROSTATE.

   The prostate is generally found to be small when the organs of gene-
ration are in an imperfect condition.   Its most important anomalies con-
sist in:—

   §  1. Abnormities of Size.—And of these the most common is enlarge-
ment, resulting from hypertrophy.  It is one of the most frequent causes
of the urinary obstructions occurring in advanced life.   The  substance
of the gland in these cases appears normal, occasionally a little softened,
of a spongy elastic consistency, and succulent, i. e. its ducts contain much
secretion ; in other cases it appears tough and coriaceous, without visible
alteration of structure.  The formation of fibroid tumors (vide p. 198) is
often complicated with this benignant variety of enlargement.
   The enlargement varies much in degree ; occasionally it is so consider-
able that the gland attains the size of a fist.  The lateral lobes are the
chief seat of the enlargement, which affects both uniformly, or predomi-
nates on one side ; but the development of a so-called middle lobe (Home)
is of greater importance, in reference to the impediment it offers to the
discharge of the urine ; it not unfrequently predominates  in a most re-
markable manner, even when the hypertrophy affects the entire gland.
It rises from the posterior section of the prostatic ring, between the two
lateral lobes, and,  according  to  its size, projects more  or  less into the
cavity  of the bladder.  It presents the appearance of a rounded tumor,
of the  size of a bean, or  hazel-nut, which projects into the neck of the
bladder; it may increase to the size of a walnut, hen's or duck's egg, or
more, and then protrudes into the cavity of the bladder in  the shape of
a  smooth or rough, nodulated, slightly lobular, rounded or cordiform,
pyramidal or cylindrical tumor.
   All enlargements of the prostate impose an obstacle to the passage of
the urine, both by narrowing  the neck of the bladder and the prostatic
portion of the urethra, as well as by inducing a  change in the direction
of the  channel, by diminishing its calibre,  and by dividing it.  The last
two malformations  are more particularly the result of unilateral develop-
ment of the gland, and of increase of  its middle lobe.  The former not
only produces a lateral contraction and deformity  of the canal in the
vertical direction, so as to produce a  sickle-shaped fissure, but forces it
out of  the mesial line to the opposite side; the middle lobe not only
obstructs the internal orifice of the urethra, but often narrows the neck
of the bladder by pushing it on one side, or divides it into two  diverging
passages, which reunite in the prostatic portion of the urethra.
   The results of this enlargement are hypertrophy of the bladder, dilata-
tion of the urinary passages, &c.
   A diminution of the prostate, with relaxation of the glandular tissue,
is observed in rare  cases, as accompanying atrophy of the testicles.

   § 2.  Biseases of Tissue.
   1. Inflammation.—An opportunity is scarcely ever presented of study- 
198
ABNORMITIES  OF
ing inflammation of the prostate in the dead subject, except in its results,
suppuration and abscess, or induration.   The  former occurs not unfre-
quently as the issue of  chronic  inflammation, which  exacerbates from
time to time.  The abscesses, which vary in size and number, generally
discharge themselves  into the bladder, into the prostatic portion  of the
urethra, in which case the ejaculatory ducts are destroyed, into the vesi-
culae seminales, the surrounding  cellular tissue, or the rectum;  or they
force their way along the urethra to the penis,  or into  the scrotum.
   2. Morbid growths.—a. We have never observed the  formation of cysts
in the  prostate.
   b. Fibroid tumors occur  frequently, and generally induce considerable
hypertrophy of the gland.   They are commonly of the size of a  pea, a
bean, or a hazel-nut, round or oval, and when deposited in the peripheral
layer of the gland, give rise to nodulated protuberances.   Although they
do not attain an extraordinary magnitude,  they  are of interest, on account
of the  relation they bear to analogous growths  in the uterus.
   c. Tubercle.—Tubercle of  the prostate  is  always  complicated with
tubercle of the testis, of the vesiculae seminales, and  of the allied lym-
phatic  glands.  The softening process gives rise to tubercular abscesses,
which  are enlarged by the fusion of  secondary tubercular deposits  and
thus extend beyond the gland, causing the devastations spoken of under
the head of abscess.
   d. Cancer.—Cancer in any shape rarely occurs in the prostate, which
is curious as contrasted with the frequency of its occurrence in the uterus.
Medullary carcinoma is  occasionally  found  to  attack  the prostate, and
to give rise to considerable enlargement of the gland; it may sometimes
perforate  the fundus vesicae, and  sprout into its cavity, causing a cancer-
ous ulcer  with raised edges, and of varying size.
   3. Anomalous contents of the prostatic  ducts.—The prostatic ducts, in
advanced  age, very often contain calculous  concretions; they are gene-
rally very minute, resembling fine sand or poppy-seeds, rarely attain the
size of millet-seeds, and still less frequently form conglomerations of the
size of hemp-seeds or peas.   They present a  black,  blackish-brown, or
yellowish-brown color, are very hard, and generally glossy.   Their num-
ber varies, but is often considerable,  and  a section of the  gland shows
them more or less uniformly scattered through its tissue.  The  gland at
the same  time appears very juicy, and the ducts are more or less dilated.
              SECT. IV.—ABNORMITIES  OF THE PENIS.

  § 1. Befect and Excess of Formation.—The penis may be smaller than
usual, whilst the remainder of the sexual  organs are  normal  or them-
selves imperfectly developed, or it may present some  further anomalies
depending upon an arrest of development; in the latter case it is reduced   *
in length, as is the case in  hypospadiasis and hermaphrodisia • the penis
then bears a resemblance to the clitoris.
  Fissures of the penis, or rather of the urethra, which sometimes extend
to the glans,  and  to the penis  itself, are  important.   They are  termed
hypospadiasis  and epispadiasis, the former of which is by far  the most 
THE  PENIS.
199
common.  Both present various degrees, but the first is particularly liable
to variations.   We here find the fissure affecting a greater or less extent
of the urethra from the glans backwards, or even  involving the  entire
penis together Avith the scrotum ; the penis remains in  a corresponding
state of imperfect development as to size and  form; the prepuce is also
fissured and small, the glans divided ;  in higher degrees, the smallness
of the organ, the total absence of foreskin, the  retraction of the scrotal
fissure, and the imperforate  condition, induce a  resemblance to the cli-
toris ; and mistake as to the sex of the individual will be the more likely
to occur if the scrotal fissure leads to a cul-de-sac simulating the vaginal
passage.   Epispadiasis is a very unusual occurrence, and is either limited
to the glans or extends over the entire urethra; in the latter case it  is
complicated with eversion of the bladder (fissure of bladder).
   Excess of development, except as more  or less remarkable enlargement
of the penis, is very rare ; the few observations recorded of two perfect
penes placed beside or above one another are not to be credited.

   § 2. Beviations of Size.—Atrophy of the penis, accompanied by obli-
teration  of the tissue of the glans and  the corpora cavernosa, deserves
notice; it is probably always associated with atrophy of the testicles.
   An apparent diminution of the penis is presented in the retracted state,
induced by large scrotal herniae, sarcocele, hydrocele, oedema of the scro-
tum, &c, in consequence of the  relaxation and  advance of the common
integument.

   § 3. Biseases of  the Tissues.—They affect the glans and the corpora
cavernosa of the penis.
   We meet Avith mechanical hyperaemia of all the spongy  tissues as  an
accompaniment of most of the advanced stages of organic heart  diseases;
we find a similar tumefaction of these parts in cases of asphyxia, espe-
cially when produced by strangulation.
   Inflammation of the cutaneous investment of the glans, which is gene-
rally complicated with inflammation of the internal lamina of the fore-
skin, gives rise to excoriation, exudation of coagulable lymph, adhesion
of the prepuce to the glans, suppuration, and ulceration; when chronic,
it induces exuberant formation of epidermis, and if the deeper parts of
the parenchyma  of the glans are  involved, obliteration,  cartilaginous
induration, and atrophy follow.   Inflammation of the coronal follicles  in-
duces increased secretion of a fluid, corroding smegma, and follicular  ul-
 ceration. Ulcers of a specific character present deep, white, striated, more
 or less hard, cartilaginous cicatrices, which vary according to the size of
the ulcerated surface, and the intensity of the surrounding reaction.
   Inflammation of  the corpora cavernosa, though of rare occurrence, is
brought on by contusions or by gonorrhoeal  metastases ; it occasionally
terminates in obliteration of the cells, and, by means of the inflammatory
product, in the conversion of the latter into a  cellulo-fibrous  cicatrix;
 the uniform  turgescence  of the penis in erection is  thus  permanently
 impeded.                                   .
   Among the morbid growths, we have to notice the warts occurring  on
 the glans, and carcinoma,  and carcinomatous ulcers on the  glans and the 
200
ABNORMITIES OF
corpora cavernosa; the former occur frequently, the latter very  rarely.
Cancer appears  chiefly to assume the  medullary form; it gives  rise to
considerable malformation and enlargement, and to ulcerative destruction
of the penis.
  We find an anomaly in the secretion occurring in  the shape of abun-
dant discharge of sebaceous matter,  which, in the  case of phimosis or  a
neglect of cleanliness, accumulates on the glans and round the corona in
the shape of lamellae and tubercular masses, and,  after  long  stagnation
and decomposition, brings on inflammation, excoriation, and  ulceration,
or becomes inspissated, so as to form calculous concretions (calculi glandis).

    SECT.  V.—ABNORMITIES OF THE CUTANEOUS  COVERING OF THE
                     PENIS  AND THE SCROTUM.

  § 1. Befect and Excess of Formation.—As a defect of formation, we
notice the occurrence of extreme shortness or contraction (phimosis) of
the prepuce; fissure  and entire absence of the foreskin in  hypospadiasis,
and the clitoroid arrest of development of the penis. The scrotum is small
when the sexual  apparatus is imperfectly developed,  and in cryptorchis,
and is sometimes only represented by a  slighthly corrugated  cutaneous
fold, which shows an almost imperceptible raphe,  and  occasionally con-
tains adipose cellular tissue.  In  hermaphroditic formations it is fissured
and resembles the labia  of the female genitals, in  those cases  especially
in which  the two halves are empty,  viz., when the testicles  have  been
retained in the abdomen or in the inguinal canals.
  Excess of development occurs in the penis in the shape of  exuberant
formation of skin, as a very long  foreskin (occasionally characteristic of
a particular race), in the  scrotum as considerable enlargement,  and in
either as  extreme thickness of the common integument, with an unusually
well-marked and  projecting raphe, which is continued upwards  on the
penis; there is also an accumulation of the tissue of the  tunica  dartos
and of the subcutaneous cellular tissue.

  § 2. Anomalies of Size.—Besides the congenital anomalies we have to
notice the acquired _ enlargement of the scrotum  resulting from  hyper-
trophy of the tunica  dartos,  sarcocele,  or  elephantiasis, accompanied
by  fibrous induration;  in Egypt more  especially it attains the  most
enormous dimensions.

  §  3. Biseases  of the Tissues.—The common integument of these parts
is liable to the primary and  secondary diseases to which  the  skin gene-
rally is subject;  but it is also liable to  primary and secondary  inflam-
matory process of a specific  character, to ulcerative disorganization, to
induration and   condensation, and even to  gangrenous  destruction.
Paraphimosis of the prepuce resulting from inflammatory swelling and
the ulceration which  causes the  glans to pass through the ulcerated open-
ing, and  denudes the  glans  of  its  foreskin, deserve  special mention.
The scrotum is frequently attacked by metastatic processes and by gan-
grene ; it is remarkable  for the  facility  with which it is reproduced • it  is
also subject to  leprous  degeneration, discoloration,  and to  chimney- 
THE  VAGINA.
201
sweeper's cancer.   The tunica dartos is variously affected in  the above-
mentioned processes; it is  also found to  be the seat of oedema, of san-
guineous  effusion (haematocele),  of  urinary infiltration, suppurative  in-
flammation,  fibrous induration, which is  sometimes confined to the sep-
tum scroti, of urinary fistulae,  and of various morbid growths.
                         CHAPTER  III.

         ABNORMITIES OF THE FEMALE SEXUAL ORGANS.

                      THE EXTERNAL GENITALS.

              SECT.  I.—ABNORMITIES OF THE PUDENDA.

   Arrest of development occurs in the shape of total  absence of the
pudenda; absence or  defective development, i. e. unusual smallness of
individual parts, the labia majora and minora, or the clitoris; absence of
the rima or of the commissures, i. e. unusual fissures, such as we see at
the superior commissure, accompanied by eversion of the bladder and
separation of the symphysis pubis.
   Excess of development is met with as uniform or  partial congenital
enlargement of the labia, nymphae, and clitoris, causing the latter to re-
semble a penis;  as increase in the number of individual parts, as of the
nymphae, and as precocious or extravagant development during puberty.
   Congenital anomalies of form affect particularly the nymphae ;  like the
acquired anomalies, they present several  varieties.
   The diseases of tissue are primary or secondary;  they consist in me-
tastatic inflammatory processes, varying in degree and rapidity, accom-
panied by increased sebaceous  secretion, great epidermal development,
excoriation, oedema,  superficial and profound  suppuration, condensation
and induration, gangrene of the external and internal labia; we  meet
with specific circumscribed inflammation and ulceration of the latter;
among adventitious products, condylomatous  excrescences occur in them
and on the  clitoris, varying in  size and number, and occasionally pro-
ducing extreme deformities.  We  also find hemorrhagic  effusion occur-
ring within the labia spontaneously, or in consequence of external violence
(sanguineous tumors), and, besides steatomatous (fibroid) tumors, all the
adventitious growths occurring in the cellular tissue at large.

              SECT.  II.—ABNORMITIES OF THE VAGINA.

   § 1. Befect and Excess of Formation.—The  vagina may be  totally
absent, or partially deficient; in the latter  case there is a cul-de-sac
opening externally, or the vagina terminates  blindly at a  greater or less
distance from the labia, or opens  posteriorly into the urethra—in this
instance the development takes place from both points, but  an intervening 
202
ABNORMITIES OF
portion is  defective,  thus  forming a  transition  to congenital atresia.
When the other parts of the sexual  apparatus are atrophied, or certain
of its sections, as, for instance, the clitoris, approach  the male type, or
in cases of hermaphrodisia per excessum, the vagina is not duly developed,
and is found rather narrow than short, smooth, and without rugae.
   We must here allude to an apparent excess  of development, called the
double vagina, or division of the vagina into two channels which lie in
juxtaposition to  one another.   It is produced by a vertical septum that
descends along  the mesial line of the vagina;  and  in  a low  degree
is indicated by a more ridge-like elevation of  the columnar rugae.  The
division of the vagina may  be complete, and is then associated with divi-
sion of the uterus and its orifice, and Avith a double hymen ; or it may be
incomplete, and in this case the septum  ceases  above, and the fornix
vaginae is common to both passages, the os tincae  being at the same time
single or double ; or else the septum does  not  reach down  to the vaginal
entrance, which is protected by a single hymen, and the vagina is single
to a greater or less  extent; or, lastly, the septum is incomplete, inasmuch
as it  presents partial defects.   The  deviation of the septum from the
mesial line, which occurs  in rare cases, is of  interest  and  importance;
the passage on one side may then be imperfect, or have a blind termina-
tion above or below.  The following  case, taken from our  collection, is
an instance:
   Sexual organs of a very imperfectly-developed female of fifteen, who
was covered with scrofulous ulcers and cicatrices, and  died of tubercular
phthisis of  the lungs and the intestines.   Two very delicate,  elongated,
fusiform uteri, each provided with one Fallopian tube and one large ovary,
unite at the point  of the internal orifice at an obtuse angle  (uterus bi-
cornis), and are from this point separated by a vertical septum, so that
each  cervix has its distinct vagina.    The two vaginae descend on both
sides of a  septum,  which is a continuation of  the septum uteri, down to
the external pudenda, which are closed by a single hymen, the left vagina
being considerably wider and presenting larger rugae than the right. The
latter terminates at about the middle of the entire vagina,  in a blind sac
formed by the  septum;  the left vagina  immediately bulges  out to the
right in the shape of a single canal.   The  external organs are, like the
uterus, in an extremely undeveloped condition.  It is a curious coinci-
dence that the right kidney was absent, the left being at the  same time
enlarged, and its hilus directed forwards.
   The hymen is often too large, owing to  excess of  development, so as
almost to close  up the entire passage ; it deviates at the same time from
its normal shape and mode of attachment, inasmuch  as  it is  generally
connected with the  internal  labia by a small round  column, by which
means two orifices are formed which lead into the vagina.

   § 2. Anomalies of Size.—The  congenital anomalies involve a greater
 or less dilatation, such  as  we find to be peculiar to some nations ; and
the contraction which we  have spoken of  above, the  highest degree of
which is complete closure.
   Congenital atresia, which we have above classed with partial defect of
 the vagina, is commonly produced by an  enlarged hymen,  or, in excep- 
THE  VAGINA.
203
tional cases, by a horizontal or  obliquely placed membrane, which oc-
cupies different parts of the passage; if carefully examined we should
probably find that it was formed by the  adherent  parietes of a vagina,
ending above and below in a cul-de-sac.   This form of atresia would, in
that case, have to be considered as partial (and slight) deficiency of the
vagina.
  The acquired  irregularities  appear,  on the  one hand, as unnatural
elongation or dilatation;  on  the  other, as  shortening or narrowing,
amounting even to complete obturation.
  The vagina is liable to  a uniform or  partial elongation, with  disap-
pearance of the rugae and diminution of its arch, in consequence of traction
exerted by the uterus or ovaries, owing  to uterine  tumors or enlarged
ovaries  that mount into the  abdomen, or  to morbid growths that force
those organs upwards.  Prolapsus uteri, tumors projecting into its cavity,
especially fibroid tumors, polypi of the uterus, pessaries, and the like,
induce dilatation of  the vagina.
  Shortening or narrowing is the result of injury and loss of tissue that
has  been intentionally or accidentally  induced, of ulceration and the
resulting  cicatrices.   The  vagina is also narrowed when the passage  is
elongated by traction, and its cavity is diminished when the cervix uteri
becomes atrophied.
  Acquired atresia may be complete or incomplete, and result from ad-
hesion of the anterior  and posterior walls of  the vagina to a greater or
less extent,  in consequence of excoriation or ulceration;  or  it may be
produced by flat or rounded cords  that  pass horizontally or diagonally
across the vagina and reduce its  calibre.  The latter may consist  of
vaginal folds brought on by traction, or  of the membranous bands left
after the  cure of ulcerative loss of substance.

   § 3. Beviations in Position and Form.—The form of the vagina  is
modified in a manner corresponding to the anomalies which we have first
examined, and in a medico-legal point of view we have to notice the
unusual forms presented by the hymen after  it has been ruptured.  In-
stead of the  carunculae  myrtiformes, a more or less considerable annular
tumor remains ;  or if the hymen was inserted into the nymphae, one half
is left so as to form a  species  of valve, or it  is entirely torn out in the
shape of a ring.
  Among the deviations of position we  notice  intussusception and pro-
lapsus of  the vagina, which affect mainly the anterior walj  of the vagina,
and the eversion of  the anterior or posterior vaginal parietes in vaginal
hernia (cystocele vaginalis, hernia  vaginalis posterior).

  § 4. Solutions of Continuity.—-Besides the injuries inflicted by means
of  cutting instruments, which generally implicate  various  neighboring
organs, and the ruptures caused by concussion and contusion, we have
to mention the contusions  and ruptures of the vagina  occurring during
parturition,  whether or not occasioned by operative interference, and
the loss of substance by ulceration.  The contusions or lacerations affect
the vagina  alone, either superficially or throughout its tissues, or they
are associated with contusions and lacerations of the uterus ; in the last 
204
ABNORMITIES  OF
case, the injury affects  the vagina and  the  uterus  simultaneously, or a
laceration of the latter is carried  down  to  the former to a greater or
smaller extent.   Neighboring organs, and especially the  bladder, may
also be involved in the solution of continuity.
  In difficult or hurried parturition, when the  parts have  not been pro-
perly supported, the vagina, the posterior  commissure, and the perineum
may be ruptured, and when the  parturition  is effected by the perineum,
the vagina is perforated above the sphincter.
  Ulcerative destruction is not always limited to  the vagina,  but  fre-
quently gives rise to communications betAveen the cavities of the vagina,
the bladder, or the rectum, or with both at  the same time by means of
fistulae or large cloacae.

  § 5.  Biseases of the Tissues.
  1. Inflammation.—a. Catarrh affects  the vagina very frequently in
the protracted  acute, or, if blennorrhoic,  in  the chronic form, and pre-
sents the most various characters.  It may be a simple benignant catarrh,
or have the specific qualities of the scrofulous, arthritic, syphilitic, im-
petiginous, or  gonorrhoeal catarrh ; it is sometimes complicated with
blennorrhoea  of other  mucous  membranes,  and is  either  idiopathic or
symptomatic, accompanying various local inflammatory, ulcerative, or de-
generate processes in the vagina, the uterus, and neighboring organs.
  The vagina appears flabby, its mucous  membrane tumefied and pale,
invested with a pale thick coating of epithelium, or excoriated  and red-
dened, with enlargement of the follicles, which  are surrounded by a  vas-
cular ring.   It contains and discharges a secretion varying in quantity
and quality, and mixed up with the products  of the associated inflam-
matory and  ulcerative processes.   In its pure condition  it is  a white,
thin, milky, or  creamy mucous, which  is commonly secreted in  consi-
derable quantities,  and indicates an abundant formation  of epithelium
and desquamation, or it appears as a  vitreous, grumous, and viscid, or
as a yellow puriform mucus.
  Catarrh of the vagina is an important disease, not only  on account of
the extreme loss of  fluids which it often  entails, but also  on account of
the imminent danger of its extension  to  the uterus and  the Fallopian
tubes,  and the consequent  morbid  affection of these  organs.  It pre-
disposes  to  intussusception of  the vagina,  owing  to  the relaxation it
induces; it leads to excoriation and superficial ulceration, both  of the
vagina, the external pudenda,  the parts in their vicinity, and of the
cervix uteri, to closure of the os tincae, to follicular suppuration, atresia
vaginae,  permanent  hypertrophy of the follicles, and dilatation  of the
vaginal vessels.  It follows  that a cure  is effected with  extreme diffi-
culty,  and that relapses occur very frequently.
  b. Exudative processes.—In  rare cases primary croup occurs on the
vaginal mucous membrane alone ; but it exists more frequently in com-
plication with an exudative process  on the internal surface of the uterus
in the shape of puerperal disease.  As  the latter generally predomi-
nates,  the affection  is usually found to have spread from  the uterus to
the vagina.   Exudative processes with various  products occur more fre-
quently in patches, or throughout the vagina as secondary diseases, both 
THE  VAGINA.
205
as a result of puerperal affection of the uterus, as well as in consequence
of an infection of the blood proceeding from other causes, or from a de-
generation of  the  typhous  and various exanthematic processes.   They
correspond to the  condition of the blood and its products, and accord-
mgly produce  a solution of the mucous membrane and the submucous
layer, varying in  shape and  depth,  and not unfrequently  resembling
gangrenous destruction.  A loss  of substance  may ensue, and to this
cause undoubtedly many cicatrices found  in these parts are to be attri-
buted.  They also  not unfrequently extend to  the pudenda, the peri-
neum, and the nates, and give rise to extensive disorganization.
   We must make  special  mention of the  secondary  form of typhus
occurring in the vagina.   It  does not appear  to  exhibit itself in  the
vaginal mucous membrane in  its genuine form, but is often found de-
generated  into croup and  gangrene.   It  is remarkable that  an existing
blennorrhoea, especially if of a gonorrhoeal or syphilitic  character, exerts
a powerful attraction upon it.
   c. Inflammation of the submucous cellular tissue of the vagina.—It
very rarely appears in the chronic form ; it leads to considerable thick-
ening and coriaceous induration of the vaginal  parietes ; the latter at
the same time become less movable, so as  to seem  agglutinated to the
adjoining parts.
   2.  Ulcerative processes. — We here meet with the simple (catarrhal)
follicular ulcer, the circumscribed  or diffused solution of the tissues re-
sulting  from exudative processes, the syphilitic ulcer, the phagedaenic
ulcer of the os uteri, which generally spreads from the cervix uteri to
the vagina, and the true cancerous ulcer.  At  the cervix we find some
other ulcers, of which we  shall have occasion to speak more fully at  a
future period.
   3.  Gangrene of the vagina.—Gangrene is the result of pressure and
contusion produced during difficult parturition ; it also occurs in  the
shape of gangrenous  eschar and  gangrenous or putrid fusion  of  the
mucous and submucous layers.
   4. Morbid growths.—Their occurrence is altogether unusual, and even
the fibrous and cancerous  tumors  that we meet  with are but rarely ob-
served.   The  cysts  that are found in this region are developed in  the
cellular tissue  external to  the vagina, and, anatomically speaking, bear
a very subordinate relation to the  latter.
   Fibroid  productions almost invariably coexist with similar growths in
the uterus ; they may be  developed in the external fibro-cellular layer
of the vaginal parietes, and especially at their  posterior surface; they
then project with  a larger or smaller segment, in the shape of round
tumors, into the vaginal cavity.  In other instances they are developed
in the cellular tissue that is  interposed between  the  vagina and  the
rectum, and, though in close relation to  the vagina in point of origin,
project  chiefly into  the rectum, and more  or less  obstruct its inferior
portion.   The  latter circumstances are characteristic of the relation in
which these morbid growths  stand to  the uterus  and to the accumu-
lations of cellular tissue which occur in these regions.
   Carcinoma of the vagina is, in most cases, cancer of the uterus which
has spread to the vagina;  however it may exist, though the  latter is in 
206
ABNORMITIES  OF
a very undeveloped state, and even without  it, in the shape of primary
carcinoma of the vagina.   It belongs to the fibrous or medullary variety,
and, in proportion to its  growth, induces thickening of the parietes, tu-
berculated condensation of the internal surface, and corresponding con-
traction of the passage ; the vagina becomes  adherent to the neighboring
parts, in consequence  of cancerous degeneration of the cellular tissue
surrounding it and  the  rectum, and finally cancerous  ulceration and
excrescences are established. ' The greater part  of  the vagina generally
becomes  involved, and the lower  portion is prolapsed;  the disease ex-
tends to the rectum, the  bladder,  the urethra; by the pressure it. exerts
it causes retention of the urine and dilatation of the bladder, and, when
it  has reached  the  ulcerative stage,  recto- and  vesico-vaginal fistulae
result.

  § 6. Anomalies of the  Contents  of the  Vagina.—Under this head we
class, besides the anomalies of the mucous secretion in vaginal catarrh,
the products of exudative and ulcerative processes, the  contents of the
bladder and the rectum,  when  introduced by fistulous communications,
the products of the diseased mucous  membrane of the uterus and the
Fallopian tubes ; blood that may be derived from various sources, and in
various states  of  coagulation,  discoloration, and decomposition.   The
presence of blood  assumes particular importance when  it is retained by
a redundant hymen,  or by congenital or acquired obturation ; we include
in this category pessaries and  the  adherent calculous deposits, various
substances that have been introduced from without, and, lastly, the pro-
blematic  cases of vaginal pregnancy.
                   THE INTERNAL SEXUAL ORGANS.

              SECT. I.—ABNORMITIES OF  THE UTERUS.

  § 1. Befect and Excess of  Formation.—Complete absence  of the
uterus must be considered as extremely rare ; in most cases in which the
uterus was found deficient in the dead or living subject, rudiments of a
uterine organ of different forms were discovered.1
  The most  common case of  arrest, which is generally considered as
absence of the uterus, is that in which the fold of the peritoneum, which
is destined for the reception of the internal sexual organs,  contains, on
one or both sides, posteriorly to the bladder, one or two small, flattened,
solid masses, or  larger hollow bodies, with a cavity of the size of a pea
or a lentil, which  is  lined with mucous  membrane.  They  are to be
viewed as rudiments of the uterine horns, and the Fallopian tubes  bear
an exact relation to their development.  These may either be totally de-
ficient, or terminate in the vicinity of the uterus in  the peritoneum as
blind  ducts, or they may communicate with the uterus with or without
an open passage.
1 Oestr. Jabrb. xvii. 1. 
THE  UTERUS.
207
  This formation of the uterus, and  especially the existence  of two
lateral, hollow, elongated and rounded uterine rudiments, each of which
is connected with a corresponding Fallopian tube and ovary, constitutes
what Mayer terms the uterus bipartitus.   From each of the uterine rudi-
ments  a flattened, round cord of uterine tissue ascends within the fold of
the peritoneum, and the two from each side coalesce.  The place of the
uterus is occupied by cellular tissue, in which a few uterine fibres, de-
rived from the just-mentioned cord, may be traced;  it  presents the
general outline of a  uterus, and, reaching downwards, rests  upon the
arch of a short vaginal cul-de-sac.   The external sexual organs and the
mammary  glands, as well as the general  sexual character of the indivi-
dual, attain a normal development.
  If we pursue the  progress of these uterine  rudiments we  find a de-
velopment on  one  or both sides; representing in  the former  case, a
uterine half, or a uterus unicornis; in the latter, a two-horned  uterus,  or
uterus  bicornis, varying  in degree; this  is  what is falsely  called the
double uterus,  uterus duplex.   These, and the following uterine forma-
tions which depend upon fissure, offer considerable interest.
  The  one-horned uterus may  be always demonstrated to be a uterine
half, developed from  a  rudimentary uterine  horn, or the unsymmetrical
half of a uterus bicornis, either of  the right or the left side.  It is a
cylindrical or  fusiform body, that is curved towards the corresponding
side, and from the superior portion of which a tube passes to the ovary.
The following  are the proofs  of its resulting  from  an arrest of develop-
ment ; it presents:
  Firstly.  A vertical diameter, which generally  resembles that of a
normal uterus;
  Secondly. A diminution of the transverse diameter ;
  Thirdly. A small (virginal) fundus, with a preponderating thickness of
the long and spacious cervix (foetal state);
  Fourthly. The arch in which this uterus is deflected from the meridian
is variously curved;
  Fifthly. The cervix, as it descends, corresponds more  and more to the
axis of the body, and its vaginal portion  entirely coincides with it.  In
the virginal uterus the latter  is always  small, and the vagina narrow;
  Sixthly. In  the  os tincae  the palmae  plicatae approach closer to the
convex margin of the uterus;
  Seventhly,  The broad ligament  on the side of the  deficient uterine
half is in some cases remarkably large;  it  at least presents sufficient
room for the absent symmetrical half of the uterus.
  The Fallopian tube of the defective  side  shows various  relations;  if
there is no indication of a uterine  horn it is almost always absent, and
the broad  ligament generally forms a  slightly fringed  prolongation  at
the point corresponding to the  free end of the tube.  Occasionally it is
even absent when there is a  rudimentary uterine horn, and it presents
the relations described at p. 206.  In rare cases we  find a total absence
of one half of the uterus, whilst  the corresponding tube terminates
blindly in  the convex margin  of the  one-horned uterus above its cervix.
  The  ovary of the defective side is, with rare exceptions,  present even
when the Fallopian tube is wanting. 
208
ABNORMITIES  OF
  We are the more  induced to extract  the folloAving  remarkable case
from the essay cited elsewhere (Vol. III.) as  an instance  of the transi-
tion from the uterus bipartitus to the uterus bicornis, as the case of preg-
nancy in a uterine rudiment (one-half of the uterus bipartitus), Avhich we
shall have  occasion to  quote at  a  future  period, will  thus be rendered
more intelligible.
  The internal sexual organs of a tailor's wife, aet. 34, who died in the
lunatic asylum on the 24th of September, 1830,  had always menstruated
scantily, and  bore no  children, present  the  following  relations.  The
uterus has  a conical  shape, is two  inches and  three lines in length, pre-
sents a curve to the left, has tolerably thick parietes, and is acuminated
above ; the fimbriated extremity of the Fallopian tube is agglutinated to
its ovary.  On the right side there is a  very large ligamentum latum,
within which,  at a distance of two  inches from the uterus just described,
and  on a level with its superior  portion, there is a body of the size of a
hazel-nut, consisting of uterine  tissue, and presenting  a  cavity of the
size  of a lentil, into  which a  tube an inch and a half long, and of a
sigmoid serpentine form, opens.  Posteriorly this uterine rudiment sends
off a carneous prolongation, representing the ovarian ligament, anteriorly
it gives off a round ligament.  On its inner side  it is prolonged  in the
direction of its axis, i.  e. obliquely downwards, as a solid band of uterine
substance, which impinges upon the convex  right  margin  of the  left
uterus one  inch above  its external orifice.  Both ovaries are small and
contracted, the cervix is small, the vagina narrow, and its arch infundi-
buliform.
  If the two rudiments of the uterus bipartitus are developed uniformly,
according to  the type  of the one-horned  uterus, two uterine hahres are
formed, which unite  at one  point of their convexity, and thus give rise
to the uterus  bicornis.   The degree of  this abnormity  varies, and  de-
pends chiefly  upon the point at which  the two halves coalesce.  The
nearer the  latter approaches to the external orifice, the more obtuse will
be the angle  at which  the junction takes place,  and consequently the
more extensive the fissure.   The  higher  the point  of union, the more
acute will be the angle, and it may thus become so small  that the  two
halves lie almost parallel to  one  another, and  there  is  only a  slight
divergence of the two  horns.  In  the  latter case the uterus closely  re-
sembles the normal condition; there is always  a shallow  excavation of
the fundus between  the projecting horns;  the  uterine  cavity is  either
simple or divided by a septum of varying length.
  The part that unites the  two  uterine halves always represents the
fundus uteri;  the higher it  is placed, the more  this character  becomes
evident; and  when  it  attains the same  level as the uterine horns and
surmounts  them with its arch, the form of the two-horned uterus  disap-
pears.  We consequently find, firstly,  that  the  commissure in all cases
occupies a horizontal  position in  the  angle  in which the two uterine
halves meet.
  Secondly.  That the  commissure  is  always developed in conformity with
the fundamental type, viz. that it is a portion of uterine tissue presenting
an arch posteriorly, or rather being obtuse-angled and thicker behind. 
THE  UTERUS.
209
   Thirdly. That when a septum exists it always proceeds from the com-
jnissure.
   Fourthly. That, however low the commissure be placed, it exerts  an
 evident influence upon the mutual position of the two uterine halves and
 the internal conformation  of their cervices.  This consists, in the first
 instance, in the slight convexity of the posterior, and the slight concavity
 of the anterior, surface  of  the uterus bicornis; and in the peculiar rela-
 tion of the two uterine halves to one  another, which is marked by a
 slight convergence and inclination anteriorly, thus affording the charac-
 ter of a  normal uterus.   The influence too that is  exerted upon the pal-
 mae plicatae in the uterine halves is singular;  the  anterior one is placed
 internally next to the septum, the posterior  one  lies more externally,
 and on account of the greater thickness  of the fundus  uteri—correspond-
 ing to the normal character—more towards the posterior surface.  The
 fact of the fundus being wedged in between the cervices in its original
 form, causes the palma plicata posterior to diverge still more; it induces
 a slight rotation of  the  uterine  halves  anteriorly, which  is followed  by
 the above-described form and position of the uterus bicornis.
   The septum, which descends from the fundus uteri, may  reach down
 to the os tincae and divide  it, or it does not reach so far, and then the
 orifice or  the  cervix is common to both halves,  or, lastly, it may  be
 nearly or  totally absent, and we then find the cavity of the cervix and
 the uterus more or less uniform,  in  proportion as the  fundus itself is
 more or less elevated.   If the latter is much depressed and  presents no
 septum, a single cervical channel conducts into two uterine  halves that
 diverge  considerably, sometimes so far as to assume a  horizontal posi-
 tion.
   In rare cases, the two uterine halves do not coalesce, owing to coex-
 isting malformations, such  as fissures of the abdominal and pelvic parie-
 tes,  of internal organs, especially the bladder and  the intestine; the
 uterus thus remains completely divided, and the two hah^es are separated
 by the rectum, the  colon, the small intestine, or by a rudimentary por-
 tion  of  either, by the  mesentery,  or the bladder.  In  the  majority of
 cases, the inferior section of both,  or at least of one uterine half, is but
 very imperfectly  developed, and this applies still more to  the  vagina
 and to the pudenda.
   The lowest  degree of uterine fissure is represented by the  bilocular
 uterus.  Here the projection of the uterine  horns has  entirely  disap-
 peared ; the fundus uteri occupies a position level Avith the orifices of the
 Fallopian  tubes, and its convexity projects  above them.   The uterine
 cavity is divided into two vertical partitions by a central septum; the
 uterine horns present a normal divergence and the normal length.  Yet
 even here  the division of the uterine cavity is  perceptible  externally;
 the body of the uterus presenting greater breadth, and generally a shal-
 low  fundus, in consequence of which  the uterus appears  lower, and
 its dimensions do not, in most cases, exceed those  of the  normal uterus;
 the  division is also indicated by  a shallow furrow  running down the
 posterior surface of the  organ.
   The division of the uterine cavity by  a vertical septum into two loculi
 extends  in rare cases into the external orifice, but more generally is
    VOL. II.                        14 
210
ABNORMITIES OF
united to the cavity of the uterus, or the septum does not even suffice to
divide the uterine cavity:  Avhen this malformation approaches the nor-
mal character of the organ, we merely observe a ridge on the fundus and
along the posterior wall of the uterus, representing a rudimentary sep-
tum.   If the  septum does not reach the  external  orifice, its lower free
border is always thinner,  pointed, and falciform.   It  probably always
descends lower at the posterior than at the anterior surface of the uterus,
and this becomes particularly apparent when it merely exists  in  a
rudimentary state.
   In the case of the uterus bicornis or bilocularis,  the vagina is either
single, or may in either be divided in all the forms and degrees described
at p.  202.   The  most perfect fissure seen is that in which the septum
of  a uterus bicornis  or bilocularis descends  to  the external orifice,
divides the latter, and extends to  the vagina; the  septum may reach  as
far as the pudenda, and in the virginal state divide the hymen.   In this
case there is a separate vagina for each half of the uterus.
   All these malformations of the uterus  occur associated  with  various
irregularities in other organs, as also in individuals that in other respects
are well developed.  In reference to conception, pregnancy, and partu-
rition, connected Avith the  uterus bicornis, bilocularis, and unicornis, we
have to make the folloAving remarks.
   Firstly. Numerous well-authenticated observations prove that the ano-
malous conditions of the uterus which we have discussed, i. e. the uterus
bicornis and bilocularis,  with or without division of the vagina, and even
the uterus unicornis, are capable of being impregnated.   In the first we
find repeated pregnancy occurring in either half, but there is  a prepon-
derance in favor  of the right side.   There are even cases on record of a
tAvin  pregnancy occurring in one, or  of concurrent pregnancy in both
halves; one foetus has been found less deAreloped and smaller, and  in
solitary cases perhaps—though this is to be received Avith certain doubts—
superfcetation had taken place.   In the Viennese Museum we have even
an example  of pregnancy in a  rudimentary uterine  horn, which termi-
nated fatally in the third month by rupture and sanguineous effusion into
the peritoneal cavity.   The case was formerly taken  for impregnation of
the Fallopian tube, until a further examination convinced me to the con-
trary.  It is highly instructive, and doubtless the  only case of the kind
on record.   We shall, therefore, devote a little further attention to it.
   The true  uterus is a uterus unicornis of the left side with a cervix,  in
which cicatrices that have been left by former births  are visible ; the left
Fallopian tube issues from its apex, which is turned to the left side.   A
tolerably thick, roundish, flattened, and hollow cord, consisting of uterine
parenchyma, is inserted into the convex right margin of this uterus and
communicates by a millet-sized opening just above the internal  os uteri
with the cavity of the latter.   This cord is above two  inches in length,
and is dilated externally into a sac of the  size of a duck's egg, from the
termination of Avhich the right tube Avith its ovary, and from  the lower
surface a round ligament proceed.   This sac, the  rudimental right half
of the uterus, contained a  female  foetus of the third month enclosed in
the normal membranes; it presented a transverse fissure, in the vicinity
of the insertion of the umbilical cord,  of  almost tAA'o inches in length.
All the membranes Avere ruptured.  The  left  half of  the  uterus is twice 
THE  UTERUS.
211
as large as it would be in an unimpregnated state, its walls thick, and
its innner surface, as well as that of the channel  of its parenchymatous
process, invested by a  deciduous  membrane, and  the  cervix blocked up
with a plug of coagulable lymph.
   The preparation was taken from a maid-servant tAventy-four years of
age, who had died suddenly after attacks of pain  and spasm in the abdo-
men on the 24th of March, 1824, and was examined by order of  the
sanitary board.   The body was  delicately  built and rather emaciated;
four pounds of blood, which had been effused in consequence of the rup-
ture of the pregnant rudimentary uterus and the foetal membranes, were
found in the lower part of the abdomen.
   The formation of which we are speaking, is  the same as the transition
form from the uterus bipartitus to the uterus bicornis described at p. 208,
with the  exception that in this case the  parenchymatous cord  that
passes from the rudimentary to the developed half of the uterus is hollow,
and contains a channel which  establishes a  communication  betAveen the
two, whereas in  the other case  the cord  is solid.  By  means of this
channel impregnation of the rudimentary uterus was rendered possible ;
this pregnancy forms a species of transition from  uterine to extra-uterine
pregnancy, and particularly to pregnancy in the Fallopian tube.
   Secondly. In reference to the course of  pregnancy and of parturition
in uterine formations  that are  capable of being impregnated, Meckel
concludes, from  a review of the cases that had been published in his time,
that of the comparatively small  number of cases of fissured uterus  the
majority died during  or  after  birth; this ratio is increased by the con-
sideration that in the great majority of these  cases the  malformations
occurred in monstrosities, children, and  virgins.   Since  Meckel, Carus
has directed particular attention to the unfortunate issue  of these cases.
Numerous  cases may now  be opposed to  the ancient and modern  ob-
senrations of the above description, but it appears that the unfavorable
ratio pointed out by Meckel still holds good with regard to  the uterus
bicornis and bilocularis.
   Various circumstances conspire to induce great distress or rupture of
the  womb, even during  the  early periods of pregnancy  (Canestrini,
Dionis), to give  rise to abortion, flooding,  difficult and slow parturition,
with consequent exhaustion and predisposition  in the uterus to puerperal
disease.   They become apparent on examining the fissured organ,  and
we find them to  be the following.
   a. The absence of the necessary dimensions in the uterine half that
undertakes the functions of the  entire organ during pregnancy, and the
development of which is  only provided for by  one _ set of  vessels.   This
applies with additional force to a rudimentary uterine half, as in the case
just detailed; in reference to its termination in rupture also, it is allied to
extra-uterine pregnancy, and especially to pregnancy in  the Fallopian
tubes.
   b. The obstacle opposed to the uniform development of the impregnated
uterine half by the unimpregnated half.  It appears that the latter, after
the formation of a more or less  complete decidua, keeps  pace in its de-
velopment with  the impregnated half up to a certain point only, and then
remaining stationary, forms an impediment to the uniform  growth of that
half.  This observation is particularly applicable to the bilocular Avomb, 
212
ABNORMITIES  OF
with a complete septum, as the latter being common to both cavities, re-
mains undeveloped on the side of the unimpregnated portion;  it applies
less to the true uterus bicornis, the two sides of which are independent
of one another.
  c. The nearer the uterine  malformation approaches  the uterus bicor-
nis, the more the two halves of the  organ diverge from the axis of the
body and the pelvis.  In the bilocular uterus, the uterine halves are tole-
rably parallel to the axis of the body;  in the uterus bicornis they form
an acute, or even almost a right angle with the latter.   The impregnated
half of the uterus certainly shoAvs this deviation; but in the uterus bicor-
nis  it appears to diminish, whereas in the uterus bilocularis it  seems to
increase.   The axis of the impregnated uterine half is  therefore certain
to meet with the vaginal axis in an  obtuse angle ;  consequently, during
the act of parturition, the direction of the uterine force  and of the expul-
sion of the foetus will cross the axis of the pelvis, and fall upon the pelvic
parietes that lie  opposite to the vertex of the pregnant half of the womb.
The direction of the impregnated half and of its force, will also be influ-
enced by the unimpregnated half, which during the act of parturition rests
upon the pelvis,  and especially on the linea innominata of the correspond-
ing side.
  d. The fundus uteri and its expulsive power is of particular importance
in the act of parturition.  The uterus  bilocularis  has  only one  half of
this part of the organ, and in the uterus bicornis it is totally deficient.
  e. Carus considers the impediment to the discharge of the superfluous
amount of blood from the uterus to be the cause of the fatal issue which
commonly follows  birth  in the case of  fissured  uterus.  In  the normal
uterus the return of the blood  accumulated  in  the pregnant womb is
effected by means of two sets of vessels ; whereas in the fissured uterus,
each half of which is supplied by separate vessels, one-half of the venous
channels only can carry off the  blood.   Consequently,  although  the
single uterine horn becomes almost  as much developed as the undivided
uterus, an unfavorable  relation is established,  from one set of vessels
only being charged with the entire quantity of blood that has to be re-
turned.   Besides the above arrests of development, we find, not so much
in new-born infants as in the later periods of life,  an imperfect develop-
ment of the uterus occurring  in reference to its size, its tissue, and espe-
cially to its vascular system;  the organ remains small  and  retains  the
foetal or infantine character.
  Excess of development, except in the shape of precocity, does  not
occur; the cases on record of plurality of the uterus are to be viewed as
cases of fissure.

  § 2. Anomalies of Size.—These consist in irregular enlargement or
diminution.
  The former either occurs as precocious development, depending upon
a congenital vice or accompanying early puberty, or it is the result of
morbid increase of size, depending chiefly upon hypertrophy or dilatation.
  'Hypertrophy either affects the entire  uterus uniformly, so that its  nor-
mal  form and the relations of the different parts in point of size  and
capacity are preserved, or it  affects one segment alone,  and this partial
hypertrophy is particularly remarkable  in the cervix. 
THE  UTERUS.
213
   The hypertrophy varies in degree ; it not unfrequently reaches such an
extent, that the uterus attains the size of a goose's egg, or of an ordinary
fist, and that its parietes present a thickness of from six to nine lines.
   In hypertrophy of the cervix, the coexistent malformation is remarkable.
The two labia of the os  tincae often enlarge  uniformly, so as to form an
annular tumor;  they more frequently represent two cylindrical  swellings,
separated by lateral fissures or oblong tumors that are turned up outside;
still more frequently Ave find the anterior lip to be the seat of hypertrophy,
and it is often elongated so  as to form a simple, cylindrical, or conical
teat-like body, or if the cicatrices resulting from previous lacerations pre-
vent the uniform enlargement, it assumes the appearance of an indented
or lobulated appendix, and various other strange shapes.
   Hypertrophy is caused  by previous and repeated pregnancy, by idio-
pathic or consensual irritation of the  uterus,  the latter involving the fre-
quent coincidence of hypertrophy of the uterus with diseases of the mam-
mary glands, by prolapsus, and by tedious vaginal, and especially uterine
catarrh.   Morbid growths, and  above all, fibrous tumors developed in
the A'icinity of the  uterine mucous membrane, and projecting into the
cavity of the uterus, are  another common  cause of hypertrophy; on
account of the numerous peculiarities presented in these cases, we have
hitherto excluded them from our investigation, and shall leave them to
be discussed at a future  period.
   Among the cases of dilatation of  the uterine cavity, we have first to
notice the one  in  which it is complicated with hypertrophy caused by
fibrous polypi, and  which resembles pregnancy, and then those important
cases in which the dilatation  is the result of  an accumulation and  reten-
tion of the mucous secretion in blennorrhoea, and  of tubercular pus in
tuberculosis of the uterus.  According  to the seat of a stricture or of
atresia at the internal, or at  this  and the external orifice of the womb,
we find the uterus converted  into a simple globular, or into an hourglass-
shaped body; dilatation of the proper cavity of the uterus sometimes attains
such a degree as to be capable of containing a hen's or even a goose's
egg.  We shall  speak of this under the head of acquired anomalies of
the shape, as well as  under that of textural changes of the uterus.
   Unusual smallness  of  the uterus occurs in the shape of arrested deve-
lopment, and is  the more conspicuous if  affecting individuals at or after
the age of puberty.   The entire uterus, but especially its neck  and vagi-
nal portion, is small, dense and hard in structure, and anaemic, its mucous
membrane  smooth  and  attenuated, the  follicles and folds undeveloped,
and the remainder  of the sexual apparatus, and particularly the OA-aries,
in a corresponding  state  of imperfect development.   The affection may
also consist in an acquired diminution, reduction, or atrophy of the uterus.
  Atrophy generally  affects the entire uterus uniformly, though it some-
times predominates in the cervix.
  Atrophy of the entire organ is presented in its most remarkable form
as marasmus or  senile atrophy; sometimes occurring very soon after the
climacteric change, and especially in consequence of tedious catarrhs
which have ceased with the cessation  of the menstrual discharge ;  some-
times occurring  even before this  period from debility or  exhaustion of
the uterus, consequent upon a rapid succession of births, or upon blennor- 
214
ABNORMITIES  OF
rhoca.   This condition  is  generally combined with  contraction of the
uterine  cavity (concentric atrophy), or with partial contractions, atresiae
of the cervix, thinning  (atrophy) of the uterine mucous membrane, and
accompanied either by increase of density and coriaceous toughness  of
the uterine tissues, or by another change  of peculiar importance, great
friability and softness.
  A thinning of the uterine walls  is  also observed  to occur in various
degrees, as excentric atrophy in the above-named dilatations of the uterus.
  Atrophy of the cervix is of great importance on account of its occur-
rence in young subjects at the age of puberty, and from its probable evil
influence upon conception.   It has not been as yet clearly demonstrated
how this affection is caused.   The cerA'ix becomes smaller in consequence
of the condensation of its tissues, and at the same time the arch of the
vagina is considerably diminished.
  Atrophy of the  entire cervix is often induced by the tension and trac-
tion resulting from the  consecutive malpositions of the uterus, which ac-
company enlargements of the ovaries and large fibrous tumors of the ute-
rus ; in the latter case it is not unfrequently associated with hypertrophy
of the body of the uterus.  It is recognized in  the liAring subject by the
elongation  of the vagina, and the concurrent disappearance of the cervix,
and the conical  shape of the vaginal  fornix.   In  rare cases, Avhich we
shall have occasion to investigate more  closely at a future period, the
affection attains such a degree as to induce solutions of continuity in the
cervix.
  Diminution of the uterine cavity presents the various degrees of  stric-
ture, atresia, and obliteration.
  Strictures and atresiae occur generally at one  or  both orifices of the
cervix, but rarely at other points; from here they occasionally extend  so
as to give rise to a partial or entire obliteration of the  uterine cavity.
The causes  of  their origin, both in  reference to the physiological and
pathological conditions of the organ, have not as yet been fully explained.
Our OAvn observations lead us to adopt the view that, in old persons, it is
caused by an excessive concentric diminution from marasmus (a tendency
in the retrograde organ to complete obliteration); in younger individuals,
by  chronic, and especially by gonorrhoeal catarrh of the uterus.
   Contraction of  the internal orifice   is caused by concentric  atrophy,
by  curvature of the uterus, or sometimes  by a fine  duplicature of the
mucous membrane.   Atresia of the passage is either induced by delicate
tendinous deposits of epithelium, or by agglutination of the mucous sur-
faces ; the external orifice becomes contracted by inflammatory swelling
hypertrophy, and cancerous degeneration of the cervix ; it  is  closed  up
by  the formation of a whitish layer of epithelium, or by agglutination of
the mucous  membrane  ; or, in rare instances, by parenchymatous adhe-
sion subsequent upon injury, inflammation, and  ulcerative loss of sub-
stance.   The two orifices  and the entire cervix may also be  blocked
or  closed  up  by  hypertrophied follicles, mucous polypi   cancerous
growths, &c.

    3. Anomalies  of Form.—Besides those malformations of the uterus
which we have alluded to as resulting from arrest of development   we 
THE  UTERUS.
215
have here to mention congenital obliquity of the uterus.   Although many
doubt its existence, occasional  opportunities occur of observing it in a
greater or less degree of development.   It presents  several varieties;
the simplest and original form is that in which two lateral halves of the
organ are so changed in position that the upper margin does not occupy
the horizontal position, and that consequently one horn and its Fallopian
tube is placed higher  than the other, and the  cervix presents a corre-
sponding degree of obliquity.   The  upper border slants to either  side,
and its axis forms an angle with the mesial line; a vertical line would
divide it in such a manner that the greater  part  would belong to the
elevated side.   The inferior  half of the uterus is generally bent, or
forms an angle at the internal orifice, the higher  portion being at the
same time much thicker and more massive.  The obliquity may confine
itself to the body of the uterus, and  the latter then  forms an angle
with the cervix, which either remains perpendicular, or, in rare cases, is
even deflected in the opposite direction.   A slight degree of this anomaly
is presented in a preponderating development of either horn.  In many
of the last-named cases the uterus assumes the appearance of a retort.
   Obliquity is probably of  importance in reference to conception, preg-
nancy, and parturition.  It must be distinguished from the mere slanting
position of the uterus.
  Among the acquired malformations we  first notice the oblique position
induced by traction exerted upon one side by fibroid tumors, or by an
enlarged ovary which has risen into the abdomen.  Then those  malfor-
mations are to be mentioned which the uterus presents in consequence of
traction exerted uniformly on both sides,  of fibrinous  tumors developed
within its parietes, and those presented  by the  vagina in hypertrophy,
from cicatrization after rupture or ulcerative loss of tissue; lastly, there
are the malformations accompanying dilatation of the uterine cavity, and
the  development of a uni- or bi-locular  capsule.  If the cavity of  the
uterus alone is the seat of an accumulation of mucus,  OAving to  stric-
ture or obstruction of the internal orifice, the former dilates into a globe,
which appears seated upon the cervix as upon a stalk;  if a similar accu-
mulation  takes  place in the  channel  of the cervix from stricture  or
atresia of the external orifice, the cervix is converted into an ellipsoid
capsule, and we  then have two cavities, one above the other, separated
by an isthmus, and  resembling an hourglass.   Mayer has termed this
malformation of the uterus the uterus bicameratus vetularum.

   § 4. Beviations of Position.—As a congenital anomaly of this variety,
we have to mention  the oblique  position of the womb, brought on by
shortness of one  of the broad ligaments,  which it also  retains in the
impregnated state.  Among the acquired deviations of position, we have
first to mention  anteversion, retroversion, and the  less  frequent  and
less important lateral deviations of the uterus.  Retroversion is the most
frequent,  and this may even affect the pregnant uterus.
   A condition to which hitherto little attention has been paid, consisting-
in an angular deflection of the fundus from the cervix uteri, must be care-
fully distinguished from the two former  irregularities.   This deflection
almost always takes place forwards (Walshe's anteflexion), and very rarely 
216
ABNORMITIES  OF
backwards (retroflexion);  the latter  never considerable,  Avhereas the
former not unfrequently attains such an extent that an angle of 90° and
less results.  The fundus uteri, in this  case, occupies a horizontal posi-
tion, or may even direct its posterior surface forwards; and occupies the
cul-de-sac placed betAveen  the uterus and the bladder.  This deformity
would appear to be an excessive increase of the shallow anterior  curva-
ture developed at the period  of puberty, and a separation and division of
the uterine cavity from the channel of  the cervix, consequent  upon the
preponderating development  of the body of the uterus.  It is of  impor-
tance, as it induces similar symptoms  as anteversion  and retroversion,
and also as it probably interferes with  conception in the same manner as
the congenital  obliquities  that  are  complicated with similar lateral de-
flections, viz. from contraction of the internal orifice.
   We have here  also to mention prolapsus of the womb, which, as Fro-
riep has satisfactorily demonstrated, may occur  spontaneously in  conse-
quence of traction exerted upon the womb by the vagina, in the shape
of hernia vaginalis posterior.   The uterus appears  extended;  in  conse-
quence of the dilatation of the venous plexuses, and the impediment  offered
to the circulation by pressure, it becomes the seat of hyperaemia; there
is increase of size and substance (hypertrophy);  and  the cervix,  at the
same time, from being exposed to  atmospheric and  other  influences,  is
attacked by active congestion, increased secretion, exuberance of epithe-
lium, inflammation, &c.  Spontaneous prolapsus occurs in the unimpreg-
nated uterus, and presents various degrees ; so-called  accidental prolap-
sus is developed rapidly, it may be brought on immediately or soon after
parturition by direct exciting causes, and be complicated with partial,  or
in rare cases with complete,  eversion of the uterus.
   Lastly, we find the position  of the  uterus variously affected by en-
largement or dilatation of neighboring organs, by pelvic tumors, mal-
formations of the pelvis, &c.

   § 5.  Beviations of Consistency.—We shall subsequently advert to nu-
merous  deviations in the  consistency of the uterine  parenchyma, and
especially to a  diminution of consistency, resulting from various morbid
processes; but an increase or diminution in the consistency  occurs even
without apparent disease of the tissue.
   Diminished consistency is  not only presented as  a  relaxation  of the
uterus accompanied  by marasmus, consequent upon the  exhaustion in-
duced by parturition, or arising from  paralysis of  the uterine fibre  in
puerperal diseases, but it also occurs in  a distinct form as  pulpiness
(marciditas),  slight friability  or fragility.   It very frequently affects the
decrepit  uterus, involves  chiefly  the fundus, and appears generally  to
result from exhausting uterine  discharges.   The tissue of the affected
uterus is of a pale or yellowish red, or  sometimes ashy color it is torn
by the slightest  effort, its vessels  are  thickened, rigid, and sometimes
ossified.   This condition predisposes more  particularly to  apoplexy  of
the uterus in the advanced periods of life, and to the consequent conver-
sion of the uterus into a sanguinolent, dark-red, and subsequently  rusty
lee-colored pulp.
   This condition is of much greater importance when  following parturi- 
THE  UTERUS.
217
tion and puerperal morbid processes that have been  complicated  with
phlebitis ;  we shall have occasion to speak more fully of this tabes uteri
post puerperium in the sequel.
   The uterus presents increased consistency as a consequence of lasting
hyperaemia, of hypertrophy or  even of atrophy; the entire organ,  or
certain portions only, as e.  g. the cervix being affected.  There are vari-
ous degrees,  from coriaceous condensation and  toughness  to fibroid  or
cartilaginous induration.                               (

   §  6. Solutions of Continuity.—Under this head we include the solitary
cases observed by old writers, of rupture of the pregnant womb  about
the middle of pregnancy, caused by a deficiency in the substance of the
uterus bicornis;  the more frequent rupture  of the uterus at  its superior
portion, in consequence of  excessive labor-pains, caused by insuperable
obstacles  to  birth  on  the part  of the mother or the child, and accom-
panied by hemorrhage and  escape of the contents into the  cavity of the
abdomen; and the still more common rupture of the uterus at its lower
segment during parturition, in consequence of various difficulties.
   The latter  generally extends  from the cervix to the vagina; it may
also affect the parietes  of neighboring  hollow viscera, especially of the
bladder;  the blood may be effused into the pelvic adipose  and cellular
tissue, in the vicinity of the bladder and the  rectum, and  between the
broad ligaments; it may pass downwards into the labia, or upwards under
the  peritoneum into the iliac and lumbar region; or the  effusion may
be accompanied by rupture of the peritoneum or the bladder, and  take
place into their cavities.  These ruptures affect the entire  thickness of
the uterine or vaginal parietes,  or are limited to an  internal layer, or
they are  lacerations of the vaginal  portion of the uterus.   They gene-
rally have a  vertical direction, transverse lacerations being very rare.
   In cases of difficult labor the  uterus may  be subjected to contusions of
more or less  intensity, which sometimes involve the entire  thickness of
the organ.   The parts adjoining the promontory, or the symphysis pubis
and the horizontal rami of the pubes are most liable to suffer.  The con-
tusions may affect a circular spot and have a various extent, or they may
be chiefly in a transverse direction.
   In rare  cases the uterus suffers a severe contusion immediately  above
the vaginal segment, and throughout its circumference,  amounting even
to laceration ; thus the vaginal segment of the uterus may at once, or by
a subsequent process  of suppuration, become detached^ and  in the case
of eversion of the uterus after parturition,  the  separation  of the entire
uterus from the vagina has  been observed (Cook).
   Finally, we have to allude to  ulcerative affections of the  uterus caused
by or resulting from malignant  puerperal disease, and in various other
"ways.

   §  7.  Biseases of Tissue.
   1.  Hyperaemia—Apoplexy of the Uterus—Anaemia.—Hyperaemia of
the uterus, and especially of its  mucous membrane, with effusion of blood
in various  states of coagulation and discoloration, is often observed in the
dead subject as menstrual congestion and hemorrhage.  It  also occurs 
218
ABNORMITIES  OF
in combination Avith tumefaction (congestive intumescence) of the uterus
and its appendages, with relaxation of its parenchyma  and the mucous
membrane, dark color, copious sanguineous  contents, and hemorrhage
into the uterine cavity, representing active or passive congestion or me-
chanical stasis, consequent upon excessive or anomalous  menstrual dis-
charge, or other injurious influences.
   Advanced degrees of hyperaemia give rise to uterine apoplexy, i. e. to
effusion of blood into the uterine parenchyma, with or without concur-
rent hemorrhage into the cavity of the organ.  It is observed in two dis-
tinct forms.
   One occurs at the period of decrepitude, and is chiefly caused by the
marcidity of the uterine tissue above  alluded to,  and by  the rigidity of
its vessels ; its main seat is the fundus uteri, to which it may be entirely
limited, or at which, if more extensively diffused, it has taken its origin,
and is most prominently  developed.  The fragile and  softened uterine
tissue presents a dark red or black discoloration, extending to a greater
or less distance from within outwards  ; the  accumulation of blood may be
so considerable as to destroy all traces of structure; it oozes from the
cut or broken surfaces, in greater or  smaller quantities, according as it
is more or less  coagulated.  The  mucous  membrane  presents a similar
condition, and the uterine cavity very  often contains more or less slightly
coagulated or fluid blood.   The posterior wall of the uterus is but rarely
affected, and if so, but to a slight extent.
   This form of apoplexy undoubtedly constitutes many of the metror-
rhagia cases that occur in advanced age ; the lower degrees may be cured,
the tissues subsequently presenting a loose, retiform, contused,  and por-
ous appearance, of a rusty or yellowish color.
   The second form results from tedious  and slow labors;  it occupies the
lower segment and  the cervix of the  uterus.   The affected portion ap-
pears dark rek, and full of blood ;  the part is dilated, relaxed, pendulous
and paralyzed,  and there may be contusion and laceration also.
   Anaemia accompanies an arrest of development, marasmus, induration
of the uterus, and general anaemia.
   2. Inflammation.—Although we shall, as much as possible, distinguish
between the mucous membrane and the uterus itself in examining this
subject, we must confess that,  as may be expected from the close ana-
tomical connection of the two, the diseases which we shall have to consider,
very readily pass from the one to the other.  Yet we  must also  affirm
that generally the lining membrane of the uterus is affected primarily,
and that this is scarcely ever the case with the uterine tissue, as far  as
can be demonstrated by the pathological anatomist, with the  exception
of the reaction following traumatic influences,  especially  of the vaginal
portion.   We shall  not at this place  devote any attention to peritoneal
inflammation, but discuss  the  inflammatory affections of the unimpreg-
nated uterus, and the  participation of the  uterine parenchyma in  them.
The uterine inflammations occurring after childbirth, Avith their sequelae
we shall consider in a separate appendix on puerperal diseases of the
uterus.
   a. Catarrhal  inflammation (endometritis  catarrhalis).__This  is  an
acute  affection ;  it occurs  in combination with inflammation of  the adja- 
THE  UTERUS.
219
     cent uterine tissues, extending to a greater or less depth and of various
     intensity, and even complicated with peritonitis ; it is frequently met
     with in the sick-room, but rarely in the dead-house:  it is here only oc-
     casionally observed in a protracted blennorrhoic stage.
       The uterine mucous membrane is  much more commonly discovered in
     a state of chronic catarrh and inveterate  blennorrhoea, which is  either
     the residue of acute catarrh, or  the result of a  similar affection of the
     vagina; it may occur as a sequela of parturition, or as a complication of
\     those morbid growths that  bear a near relation to the uterine mucous
     membrane.  The mucous membrane offers a pallid appearance, or there
     is evidence of previous stasis and inflammation, and it then presents, with
     the adjoining uterine tissue, a brownish-red or slaty color; the membrane
     is tumefied, relaxed, plicated, and secretes a grayish-white viscid mucus,
     which during temporary exacerbations, or an enduring  state of more in-
     tense inflammation, appears streaked with blood, creamy,  yellow, and
     puriform.
       Here, too, we find  hypertrophy  of the mucous membrane resulting
     from chronic catarrh, in the shape of mucous  or cellular polypi.  They
     consist of club-headed elongations of the mucous membrane, in which we
     find a group of closed  follicles,  or a lobulated tissue containing a  gela-
     tinous mucus, which is discharged from time to time in consequence of a
     dehiscence of the follicles.  These excrescences occur  chiefly at the
     fundus uteri, in the neighborhood of the insertions of the Fallopian tubes
     and in the channel of the cervix—a point at which, in the  normal con-
     dition,  large follicles (ovuli Nabothi) are  found, which occasionally un-
     dergo considerable enlargement.
       We find that the uterine parenchyma becomes more or less hypertro-
     phied during catarrh, in the same manner as other muscular layers which
     are subjacent to  mucous membranes.
       Inveterate uterine catarrhs not unfrequently give  rise to the above-
     mentioned strictures and atresiae; and if the  blennorrhoea persists, the
     dilatations  of the uterine and cervical  cavities previously discussed,
     result.   During the progress of  dilatation occurring under these circum-
     stances, the same changes that we have already repeatedly met with under
     similar circumstances, in dropsy of mucous cavities and canals, are some-
     times found to occur in  the uterus.  As  a dilatation from  the  accumu-
     lated secretion increases, the uterine mucous membrane is converted into
     a thin serous membrane, which  secretes a  colorless, serous, albuminous
     fluid, resembling synovia.   The uterus appears in the shape of a round,
     slightly-thickened, hydropic capsule, of the size of a hen's or duck's egg
     or a fist.   This condition is the  only one that really deserves the name of
     hydrometra, of which several remarkable  instances are related, especially
     by older writers.   The contained fluid may always, or for  a long  time,
     remain such as above described ; but it generally undergoes some altera-
     tions  from  the  admixture of various products of  slight inflammatory
     attacks, and especially of hemorrhagic exudations of the uterine lining,
     which give it a chocolate-colored, rusty, or black tinge.
       Occasionally temporary discharges  of these  fluids occur by the vagina
     during life, after which fresh accumulations take place.  They are to be
     distinguished from similar discharges from the hydropic Fallopian tube.
       Uterine catarrh generally suffices to produce sterility; but it often ex- 
220
ABNORMITIES  OF
tends to the Fallopian tubes, and there also gives rise to changes that are
of extreme importance in this respect.
   b. Exudative processes (endometritis exudativa).—Croupy or plastic
fibrinous exudation, Avhether or not accompanied by a similar process  in
the vaginal or Fallopian mucous membrane, very  rarely occurs on the
inner surface of the uterus, except after confinement.  It is,  at all times,
rather a secondary than a primary process.  Exudative affections of the
uterus and their varieties, occurring after parturition in the shape of puer-
peral diseases, are all the more frequent and the more numerous.
   3.  Ulcerative processes.—In treating of catarrh of the vagina, we have
alluded to excoriation, superficial and follicular ulceration of the vaginal
portion of  the uterus.  The specific  character  of  the  catarrh and the
follicular ulceration, as well as neglect of proper  attention and treatment,
cause the resulting ulcers to  present a more or  less remarkable appear-
ance in reference to the shape of their  edges, the reaction  set up, the
product and the change of texture, as well as in regard to the consequent
fusion of the  diseased tissue,  and to the concurrent tendency of disorgani-
zation beyond the ulcer.   It  is  stated that, in reference to  the first  of
these considerations, we may distinguish the simple (catarrhal), the her-
petic, scabious, and scrofulous ulcer of the  cervix;  as regards the local
process, there may be a fungous, lardaceous, or  callous  ulcer, &c.  We
also find primary and secondary syphilitic ulcers, cancerous  ulcers that
have resulted from the fusion of cancerous morbid growths, the so-called
phagedenic ulcer of the os tincae (Clarke's corroding ulcer).   The latter
may be compared to the phagedenic (cancerous) sore of the skin; Avithout
having a morbid growth for its base, it gradually destroys the cervix, and
even the greater part of the uterus, and may extend to the rectum and
the bladder.  It is an irregular, sinuous, jagged ulcer, the tissues at the
margin and the base of which are thickened or hypertrophied, in  conse-
quence of a sluggish inflammatory process ;  the base presents a greenish
and brownish-green discoloration, with a slight  glutinous and  purulent,
or a more copious watery, secretion:  there  are  no granulations, but we
find a gelatinous exudation,  and according to the state of the immediate
reaction, the  tissues are converted into the  above-mentioned products of
the ulcerating surface.
   Lastly, we find the uterus liable at different parts, and in a varying
extent, to acute or  chronic ulcerative disorganization, as a consequence
of puerperal affections; this subject will be examined in  the appendix.
   4. Morbid growths,  a.  Cysts.—Cysts are very rarely formed in the
uterus ; we have not met with a single example in Vienna, and I myself
have only inspected one case of uterine  acephalocysts.   It is necessary
to distinguish the very much hypertrophied follicles that may occur in
the uterine cervix, from newly-formed cysts.
   b. Fibroid tumors.—Anomalous fibrous tissue is the most frequent of
all new formations occurring in the  uterus, in  the shape of fibroid  or
fibrous tumors (tumor fibrosus, desmoides, formerly called sarcoma • Avhen
ossified, osteosteatoma of the uterus; scirrhus;  W. Hunter's carneous
tubercles, &c.)   These fibroid growths of the uterus not only present all
the essential characters peculiar to them elsewhere in  a  remarkable
degree, but they also offer numerous important  and accidental modifica- 
THE  UTERUS.
221
tions, some of which exert a considerable influence  upon the uterus; it
therefore becomes necessary to devote a more extended consideration to
them, in addition  to the general  outline which we have  already given.
The uterus, as well as  the adjoining tissues, are particularly liable to be
the seat of fibroid  growths.   They not only present all the varieties and
degrees as regards size and volume, shape, number,  and metamorphosis,
in so characteristic a form, that we have thought it right to take them as
the specimen and groundwork of general disquisitions on the subject, but
they also offer the most various modifications in reference to their seat,
and consequent reflex influence upon the womb.
   We also find that the changes in position of the uterus, the deviations
of its shape, and of the direction and form of its cavity, of its size in
reference to  the coexistent hypertrophy  and atrophy  of  the organ, and
the relations  of the uterine mucous membrane, &c, are very remarkable.
   The three  varieties distinguishable in the fibroid tumor, according to
its internal structure, are all found in the uterus.  The variety in which
a concentric disposition of the fibres is displayed, is here also distinguished
by its density, hardness, poverty of vessels,  smallness, and spherical
shape.
   The  second variety, in which the fibres  appear irregularly disposed,
and issue from numerous centres or nuclei, present a rounded form, and
an uneven, nodulated surface,  which indicates the aggregation of the
fibrous  centres in  reference to  density and consistency, vascularity and
volume, they offer the  extensive modifications  already spoken of; they
may, on the  one hand, be very dense and hard, and  unvascular ; on the
other,  in consequence of an accumulation of cellular tissue in the inter-
stices of the fibrous layers, they may be more  or less vascular  and suc-
culent,  or  soft and  elastic, soft and doughy, flabby, &c, sometimes re-
sembling a soft mammary gland, sometimes a coarse-grained salivary
gland.   Those fibroid  tumors, the interstices of  which are dilated  into
cells or cavities, containing a serous fluid from excessive exhalation of the
intervening cellular tissue, are of extreme importance.   They  present
fluctuation, and may, on account of the deceptive appearances accompany-
ing fibroid tumors, be  easily mistaken for ovarian dropsy, hydrometra,
acephalocyst of the uterus, or pregnancy.
   The fibrous polypus of the uterus, the third variety of  fibroid tumors,
takes it origin by a single or divided trunk in the interstitial cellular
tissue of the uterine parenchyma ; the former expands into striated fasci-
culi, which are bound together by softer vascular and cellular interstitial
substance,  and the entire mass presents a distinctly lobulated structure,
which is more or less visible externally.   The polypus  grows  into the
cavity of the uterus, with which  it is in the closest anatomical connection,
and upon the functions of which it exerts a considerable influence.  It
enlarges chiefly in one direction, and has a cylindrical, fusiform, clubbed,
pyriform shape, and is more or  less flattened;  it is provided with nume-
rous and very large  vessels, is apt to swell, and in consequence of exces-
sive congestion and  rupture of the vessels, we  often meet with  extrava-
sation  within its tissues.
   The anatomical relation of fibroid tumors to the  uterine parenchyma
is very intimate in the third variety, less so in the second,  and least of all 
222
ABNORMITIES  OF
in the first, in which the tumors adhere to the uterine parietes by a thin
layer of whitish or reddish, more or less vascular, cellular tissue, so that
they may be detached without difficulty.
   The form of the fibroid tumors of the first and second variety, we have
already described as being generally round;  in the second variety some
alterations may occur, though the globular form still predominates.   The
peculiarities of shape of the fibrous polypus, or third variety have already
been stated.   The greatest variety occurs in  reference to size.   Fibroid
tumors are found from the size of  a hemp-seed to that of a man's head.
   The fibroid tumors belonging to the second variety attain the largest
size, especially when of loose texture, and rich in interstitial cellular tis-
sue ; the fibrous  polypi also reach a considerable magnitude,  but the
fibroid tumors of  the first variety are the  smallest.  They are all gene-
rally developed slowly, though the second and third variety are occa-
sionally developed with extraordinary rapidity ; they are also liable to a
temporary increase  of  size  or tumefaction proportionate to their vascu-
larity.
   As to their number, we sometimes only find  a single, sometimes seve-
ral or many fibroid tumors in the same uterus.   We then observe tumors
of the most  different sizes  coexisting.   This applies chiefly to  the first
two varieties; the fibrous polypus  is often solitary, but it also occurs in
company with the others.
   The uterine parietes are the seat of the fibroid tumors, but not only
do they occur much more frequently in the body than in the cervix, but
in the former they chiefly affect the upper portion or fundus.   They very
rarely  occur  at the inner orifice, and if possible, still less frequently in
the vaginal portion.   This is the case with all fibroid tumors, a fact that
forms an interesting contradistinction to the  relation which  cancerous
disease bears  to the inferior segment of the uterus.   Fibrous polypus,
more especially, is apt to commence at the fundus,  and at the  orifices of
the Fallopian tubes.   The fibroid tumor is inserted into, and takes  its
origin from, the middle layers of  the uterine substance,  or it appears to
be more connected with the external layer, or even  to lie under the peri-
toneum, or again, it lies nearer the inner surface, or immediately under
the mucous membrane.   The first  two varieties are developed in  the most
various layers, though generally in the external ones; the third forms
upon the  internal layer  exclusively.  The former also very frequently
present other curious relations, whether they have been developed in the
vicinity of the peritoneum, or of  the mucous  membrane of the uterus.
In the first instance the tumor, as it enlarges, gradually becomes detached
from the uterus, dragging the peritoneum after it, and thus at last  becomes
pediculated or pendulous, by a peritoneal cord of various length.   In the
second instance it pushes the mucous membrane before it, as it enlarges,
and at last hangs into the uterus by a mucous pedicle, thus resembling
the true fibrous polypus, from which it may be  distinguished by its rela-
tion to the uterine parenchyma, and by its internal structure.
   We must here advert to a circumstance that  is not of very rare occur-
rence, viz. we sometimes find a fibroid tumor in the  pelvic cavity, and
generally in Douglas's space, without any further connection with the
uterus, except by means of cellular cords, or laminae of new formation 
THE  UTERUS.
223
(false membranes), which pass from the tumor to the uterus and its ap-
pendages, to the pelvic walls, the rectum, &c.  The question presents
itself, which is the original point of development of such fibroid tumors.
They are generally tumors which have originally been developed  under
the uterine peritoneum, and, after having become entangled in a network
of pseudo-membranous formations, resulting from the peritonitis they have
excited, are gradually detached from the uterus.   Occasionally, however,
they may have been developed Avithin the false membranes  themselves,
which is the more probable, if we consider that the new tissue as it pro-
ceeds from the uterine peritoneum, participates  in the character of the
subserous uterine cellular tissue.   Hence  it is extremely likely that Ave
really see very small fibroid tumors occasionally developed in this new
tissue.
  To these fibroid tumors,  the loose fibrous concretions Avhich are some-
times found in the pelvic cavity are allied ; they must be considered as
fibroid tumors of the uterus, which have become detached in consequence
of atrophy of the peduncle.
  Metamorphoses and diseases of the  uterine fibroid tumors.  Spontane-
ous cure.—We  have  already spoken  of ossification, congestion, inflam-
mation, suppuration, and solution of fibroid tumors generally ; and those
remarks apply Avith the more force to uterine fibroid tumors, as we as-
sumed the latter as the foundation upon Avhich  we based our observations.
Ossification occurs very frequently, congestion less so, and inflammation
and its  terminations rarely.  A spontaneous cure, under Avhich head we
must  also class  ossification, on account of the destruction of vitality in
the tumor, occurs in a few  rare cases, by a  detachment of the fibroid
tumor as it projects into the uterus,  or is suspended in it by a mucous
pedicle.  It is effected in the following manner:  the mucous membrane
of the uterus covering the apex of the tumor is in a condition of perma-
nent irritation and  congestion ; this is at last converted into inflamma-
tion, and terminates in suppuration and gangrene.  The tumor is thus
partially exposed towards the uterine  cavity, and  the destructive process
gradually involving its entire cellular investment, it becomes detached,
and passes through the opening in the uterine mucous membrane into
the uterine  cavity.  Ancient and modern cases are on record, in  which
fibroid tumors of various sizes and ossified tumors were thus discharged.
The powers of nature rarely suffice if the tumors are of considerable size,
as the extensive  suppuration necessary for that purpose is likely to prove
fatal, both  by exhaustion and by the extension of inflammation to neigh-
boring organs.  It would appear that the fibrous polypus is occasionally,
though  very rarely, discharged in a similar manner, in  consequence of
suppuration occurring at its roots and in the surrounding, tissues.
  The changes in the uterus, consequent upon the presence of one or of
several  large fibroid tumors, are numerous and  important, by reason of
the diagnostic characters they afford.
  In the first instance, the volume of the uterus increases in proportion
to the number and size of the tumors; the fibrous polypus causes an en-
largement of the uterine  cavity, corresponding to  the size of the polypus.
The increase in the substance, the hypertrophy of the uterus, which the
fibroid growths generally induce, and, on the other hand, the atrophy of 
224
ABNORMITIES  OF
 the  organ, are of greater  interest.  The hypertrophy appears as a de-
 velopment of the uterine tissue, resembling that occurring in pregnancy ;
 it varies in degree.  In reference to the latter subject, the question pre-
 sents itself by what  means the different degrees of hypertrophy are de-
 termined, and  on account of the  occasional passive condition and the
 occasional atrophy of the uterus, it is necessary still further to generalize,
 and to ask how it happens that under some circumstances the uterus be-
 comes hypertrophied, in others remains unchanged, and  in others again
 becomes atrophic ?   In answer, we offer the following remarks :
   a.  The jiearer the fibroid growths approach to the  uterine mucous
 membrane, and project into the  cavity of  the uterus, and thus maintain
 the mucous membrane in a state of irritation and inflammation, the more
 palpable is the hypertrophy of the uterus.  It is most fully developed,
 so as to resemble pregnancy, in the  case of the fibrous polypus.
   ft.  Hypertrophy of the uterus appears to be encouraged by a vascular
 state of the tumor, by the latter being less dense and capable of rapid
 growth.
   y. As also by the  development of the tumor,  during or  shortly after
 the period of conceptivity.
   8. The size of the tumor exerts no direct influence upon the origin of
 hypertrophy or atrophy.
   e. Atrophy undoubtedly results  very rarely from fibroid tumors, nor
 must we forget that they are  not unfrequently developed in the  uterus
 during the period of decrepitude, and that they  increase very slowly on
 account of the universal state of marasmus.  In  this case the atrophy
 of the uterus is  entirely independent of  and antecedent to the  fibroid
 tumors.
   The atrophy of the cervix accompanying large fibroid growths is, as
 we shall have occasion to explain more fully, the result of mechanical
 traction.
   An important change takes place in the position of the uterus, which
 may be discovered by  external examination.   Not only does a large
 fibroid tumor that occupies the external layer of the uterine tissue, push
 the organ to  the opposite side of the pelvis, but we also notice a remark-
 able ascent of the organ.  The more numerous and the larger the tumors
 are, and the more they consequently rise out of the pelvis, as it interferes
 with their growth, the more they drag the  uterus after them ; its vertical
position being also changed in proportion as the fibroid tumors prepon-
derate on one  side or the other.   This traction  necessarily causes an
 elevation and elongation of the cervix.
   The external surface of the uterus is,  as may be easily understood
variously disfigured by the projecting tumors.  In the same manner the
 cavity of the uterus, in addition to a corresponding elongation, undergoes
various alterations in form  and  direction,  proportionate to the  number
and  size  of the tumors  which project internally.   In reference to the
displacement,  we sometimes  find the entire cavity forced out of the
mesial line, at others it presents  more or less angular deflections.  The
most important disfiguration is effected  by the upward traction exerted
by numerous  and large fibroids.  The uterus, and particularly the cervix
is  elongated  to a degree  proportioned to  the degree of  traction, it be- 
THE  UTERUS.
225
comes  thinner, and  the  attenuation may, in  rare  cases, even cause a
gradual solution of  continuity, one portion remaining  attached to the
vagina, another following the upward direction of the  uterus, and the
connection being maintained by a mere  band of cellulo-fibrous tissue.
The channel of the cervix at the same time contracts, and may even be-
come entirely obliterated.   The vaginal  portion gradually disappears,
the vagina itself becomes smooth  and narrower in  consequence of the
elongation, and its arch is converted into a funnel, the apex of which ter-
minates in the os uteri.
  If one or more fibroid  growths occupy a lateral portion of the uterine
parietes, and especially if they be seated in the vicinity of the  Fallopian
tubes, the external form  of the uterus may be rendered oblique ; if under
these circumstances  the  tumors enlarge, and consequently exert lateral
traction, this may be recognized by the  elevation of the corresponding
side of the os tincae, and the increased distension of the vagina.
  Fibrous polypus gives  rise to a dilatation  of the uterine cavity, and of
the cervix, corresponding to the size of the morbid growth;  if the en-
largement proceeds to a  greater extent, the  external orifice becomes di-
lated, and the tumor projects through it into the vagina.  Large and
heavy morbid masses of this description frequently cause a slight descent
of that portion of the uterus into which  they are inserted, by the trac-
tion they exert, and sometimes even  induce complete inversion of  the
womb.
  The mucous membrane of the uterus is the more liable to catarrh and
blennorrhoea, the nearer  the fibroid tumor approaches to it; sometimes
it becomes hyperaemic, and blood is effused upon it.  This is particularly
the case with the fibrous polypus, which is not only accompanied by the
ordinary hemorrhage from the capillaries of the mucous membrane,  but
also from larger vessels of the  uterus, or sinuses of the morbid growth
that have given way to excessive traction.
  Fibroid tumors of the  uterus scarcely ever  occur before the twentieth
year ;  a fact which is established by the numerous observations made by
ourselves  and  other anatomists.   They are  even unusual up to  the
thirtieth,  and present themselves  most  frequently  shortly  after  the
fortieth year.   Without entering into an  analysis of the almost innume-
rable cases that we have  ourselves met with, we may mention the results
of Bayle's calculations as to the frequency of their occurrence ; he states
that of one hundred females  that die after  the thirty-fifth year of life,
twenty at least are affected with fibroid tumors.
  They are found in complication with the most various morbid growths
of the uterus and  its appendages; but  especially with  cancer of  the
cervix, with the corroding ulcer of the os tincae, with ovarian dropsy, &c,
still on  the whole the complication with cancer is not frequent.
  The powers of conception are commonly not impaired by the presence
of fibroid  tumors, and if  these are small, and  do not  occupy an unusual
position, they have not necessarily an injurious influence upon pregnancy
and parturition, though they frequently cause abortion  and hemorrhage
after birth.   Parturition may be very much impeded if  they occupy the
cervix uteri.   It is important to know that  these tumors become  more
vascular, succulent, and softened during pregnancy, and  assume a bluish-
    VOL. II.                       1^ 
226
ABNORMITIES  OF
 red color, so that their original appearance is entirely changed.   As the
 uterus returns to its original shape, the morbid groAvth also resumes  its
 ordinary characters.  Pregnancy is even said to give rise to hemorrhage
 and inflammation in the tissue of the fibroid tumor.
   An unusual though very important occurrence, brought on by the ex-
 cessive expansion and traction exerted by large fibroid tumors, is the lace-
 ration of the vessels, and especially of the veins.  We have once observed
 the rupture of a vesical vein (with that of the mucous membrane) folloAved
 by hemorrhage into the bladder, and in another  case the rupture of the
 subperitoneal vein of a fibroid tumor, with  hemorrhage into the abdomi-
 nal cavity, as described by other writers.
   Ligature of the fibrous polypus is sometimes followed by uterine phle-
 bitis.
   5.  Osteoid growths.—We have not met with osseous formations in the
 uterus, except in the shape of ossification of the fibroid tumors.
   6.  Tubercle.—Tubercle  occurs  primarily as tubercle of the uterine
 mucous membrane; the uterine parenchyma is like the submucous muscular
 layers, only attacked secondarily by tubercle.
   It generally occurs in the uterine mucous membrane in the shape of
 an infiltrated mass, which fuses into and attacks the uterine parenchyma
 to a greater or less extent.   The  mucous membrane appears converted
into a fissured, cheesy, purulent mass of tubercle.  The cavity of the
uterus contains tubercular  pus, which may be retained in consequence
of closure of the orifice, and accumulate so as to cause a globular dis-
tension of the organ.  The disease is very rarely observed in its early
 stage, in the shape of scattered or grouped gray miliary tubercle of the
 mucous membrane and the adjoining submucous tissue.
   Uterine tubercle is formed during childhood, in the period of puberty,
and during the prime and even, though rarely, during the  decline  of
life.   It  is  most frequently complicated with tubercle of the Fallopian
mucous membrane, and with the latter may constitute the primary tuber-
 cular  affection.   It is also found  complicated  with abdominal tubercle,
 and especially of  the  abdominal  lymphatic glands, and  of  the perito-
 neum ; and may  serve as a point of discharge for the latter.  A transla-
 tion of the  tubercular disease to the urinary passages is very rarely
 observed.
   It is curious that the tubercular deposit stops short at the cervix, and
 very rarely passes even beyond the internal orifice of the womb;  the
vaginal  portion  is never affected with tubercular disease.  This  is ex-
tremely remarkable on account of the marked contrast offered by carci-
noma, both in reference to its primary and secondary development.
   7.  Carcinoma.—Next in frequency to fibroid growths is the occurrence
 of cancer.   It always attacks  the cervix in the first instance,  and espe-
 cially that portion which projects into the vagina; the primary occurrence
 of carcinoma at the fundus uteri is so extremely rare, that the above obser-
 vation may be considered as an absolute rule.   It is contrasted in this
respect with fibroid and tubercular disease of the uterus, and it presents
a similar contrast in reference to its extension and ulcerative destruction.
   According to  our  observations, fibrous cancer very rarely affects the
uterus ; the most common form is the medullary, either by itself or com-
 plicated with the former. 
THE  UTERUS.
227
  Opportunities very rarely present themselves of investigating the early
stages of  cancer in the dead  subject; according to a feAV observations,
fibrous carcinoma, when closely examined, appears  to  consist of dense
whitish, retiform fibres, differing from the normal texture of the vaginal
portion of the uterus in which they are found, and  in their very minute
meshes a  pale  reddish-yellow or grayish translucent substance is  depo-
sited.  This  morbid growth is inserted into the uterine tissue without
well-marked boundaries; it occupies a various extent, and from accumu-
lating at certain points, gives rise to the irregular  nodulated character
and  the well-known induration Avhich accompanies the enlargement of
the cervix.
  Medullary cancer in the  first instance appears as  an infiltration of a
white  lardaceo-cartilaginous or lax  encephaloid matter, in which the
uterine fibre disappears ;  as the deposit  increases  the vaginal portion
assumes an uneven nodulated character, and appears hard and elastic to
the touch.  Cancer of the uterus very rarely presents itself in the shape
of isolated globular growths.
  As the cancerous degeneration proceeds, and especially on the  com-
mencement of the stage of  metamorphosis, with its consequent new for-
mations, particularly if they belong to the medullary variety, the lower
segment of the uterus undergoes a very considerable and rapid enlarge-
ment.  At last we find a callous, loose, spongy ulcer developed in the
usual manner, which discharges a very fetid, greenish-brown, sanious and
sanguineous fluid, and as it extends, generally causes a progressive infil-
tration of cancerous matter.  The tumefaction of the cervix and the fun-
goid excrescences not unfrequently close up the orifice, and the  conse-
quent enlargement of the womb will be the larger,  the more copious the
secretion of the mucus.
   Cancerous degeneration of the uterus is generally confined, in a very
remarkable and distinct manner,  to the vaginal portion; still there are
frequent  exceptions  to this rule, as the disorganization  is sometimes
found to  extend with great rapidity to the body, and even to the fundus
of  the uterus; this is particularly the  case if the  os tincae has already
been attacked  by ulceration.  The disease may spread downwards and
involve the vagina, thus establishing vaginal cancer.  It may extend  in
other directions, and thus  give  rise to cancerous degeneration of the
rectum, the  bladder,  the pelvic,  cellular, and  adipose tissue,  and the
periosteum; the uterus thus becomes fixed in the pelvis, and at last we
find  the peritoneum attacked, cancerous  growths being formed  upon it
and  its tissue, or perforating it, especially in  the shape  of medullary
masses.
   Cancerous ulceration spreads in the same direction;  in rare cases we
find the greater part of the uterus, and even its fundus, destroyed.   The
 destructive process, when attacking the vagina, sometimes  predominates
 on the anterior, sometimes on the posterior surface ; sometimes it attacks
both equally, and may extend downwards almost to the external orifice.
 It also involves the degenerated parietes  of the rectum and of the blad-
 der,  and generally  produces extensive  communications  between their
 cavities and the original cancerous sinus (ulcerous  cloacae).  It  finally
 extends in the shape  of sinuous passages, through the remainder of the 
228
DISEASES  OF THE  UTERUS
cancerous mass that fills the pelvic cavity, to the pelvic bones.   In thia
manner a large cavity Avith  fungoid parietes is at last established, which
occupies the greater part of the uterus and the vagina, and opens  into
the cavities of the rectum and the bladder; above it is closed in by the
fundus uteri and  the adherent rectum and cervix vaginae, as also by the
caecum and small intestine, which are agglutinated to these parts, and at
last  it penetrates into the  cavity of the peritoneum or the  intestines.
The contents of  the  cavity are cancerous ichor mixed up with faecal
matter, urine, and portions of gangrenous tissue.
   The temporary and tumultuous periods of development presented by
the peritoneal inflammations of the pelvic and hypogastric regions, which
accompany and characterize the metamorphic and ulcerative stages, and
which not unfrequently extend from the  original layer over the  entire
peritoneum, are  important occurrences  in the progress of cancerous
disease.
   Uterine cancer is, in most cases, a primary disease, and generally re-
mains for a long time, if not throughout the sole carcinomatous affection
of the organism.  However, it is sometimes developed concurrently with
or consecutively to mammary  and ovarian cancer; or it is accompanied
by degenerations  of the adjoining tissues above mentioned, and of the
lymphatic glands, which must be explained upon the theory of propaga-
tion by contact; or again, it is associated with cancer of the  peritoneum,
of the liver, the stomach, and  the breasts, with cancer of the bones, with
mollities ossium,  ovarian cancer, and universal  cancerous deposit, as  a
consequence of the resulting cancerous dyscrasia.
   Uterine  cancer most frequently  occurs between the fortieth and fiftieth
year; still  there are many cases on record in which it appeared between
the thirtieth and fortieth year, and even earlier.
   The cases of spontaneous recovery from uterine cancer are of extreme
rarity, but they do occur;  the carcinoma  and the cancerous ulceration
are then limited to the cervix, the internal orifice forming the boundary;
the loss of substance heals with a  funnel-shaped cicatrix.
   We append to the above remarks on uterine cancer a brief account of
the so-called—
   8. Cauliflower excrescence  of the os uteri, Avhich we are  inclined to
consider  as of a cancerous nature.   It is of very rare occurrence, and we
have only once observed it in  the living subject, in a form similar to that
described and delineated by Clarke.  It presented the appearance of  a
confervoid growth,  consisting of lenticular, pale  red, transparent,  and
tolerably hard corpuscles,  strung  together like the beads  of a rosary,
projecting  on the orifice  of the uterus into the vagina, and  bleeding on
the slightest touch.   It was developed and grew from an evidently can-
cerous base of the medullary variety.
   Clarke states, that it also occurs  without this complication, and that
it is curable; the unfrequency of  its occurrence and the circumstance
that after death it collapses, and merely appears like a slight accumula-
tion of delicate cellular tissue, render it difficult to decide the question
as to its  cancerous nature; this, however,  is the  view we are inclined to
adopt.
   The chief and  very dangerous symptom which  the affection presents 
AFTER  PARTURITION.
229
are frequent exhausting hemorrhages, which are brought on by the most
trivial causes.  It is said to occur at any period of life after the twentieth
year, but very rarely before that.

      SECT.  II.--DISEASES  OF THE  UTERUS AFTER PARTURITION.
  Under this head we include diseases to which the uterus is liable in
consequence of the puerperal  state, which are essentially (in reference
to causation) connected with the latter, and especially with the concur-
rent detachment  of the membranes and the  placenta  from the inner
surface  of the uterus, and which, for that reason, must be termed puer-
peral affections.   We pass  over the subjects  which have already been
discussed, and enter at once upon the consideration  of these diseases in
the following (natural) sequence.

  §  1.  On  defective and irregular Contraction  and Involution of the
 Uterus  after  Childbirth.—We occasionally find that the uterus presents
a condition  of universal flabbiness or  collapse of its parietes, accompa-
nied by a trifling  reduction of size, which must  be  considered as para-
lysis from exhaustion, and  which results from tedious  or instrumental
labor, or  from parturition,  the first stages of  which had been much ac-
celerated.  In other cases, and they are of frequent occurrence,  we find
the fundus and the neighboring parts of the corpus  uteri to be the seat
of excessive contraction and energy, whilst the inferior segment  is in  a
contrasting state of atony and collapse ; there are other cases again in
which excessive contraction prevails at the middle of the uterus forming
a zone round it, or at smaller  and less defined portions.  These occur-
rences may be brought  about by the most various impediments  to par-
turition,  by pressure, contusion of the  uterus, apoplexy of the womb
(vide page 217), by original irregular innervation of the uterus, &c.  As
may be supposed, they give rise in  the first instance to hemorrhage,  and
in consequence of this  and of the general debility,  they impede  the
further involution of the uterus, and thus protract the disposition to
puerperal affections.  We  must here mention a very singular  circum-
stance,  which may, on account of  the  consequent danger, become  im-
portant, and may even be misunderstood in post-mortem examinations ;
it is paralysis of  the  placental portion  of the uterus, occurring at the
same time that the surrounding parts go through the ordinary processes
of reduction.   It  induces a very peculiar appearance.   The part which
gave attachment to the  placenta is forced into the cavity of the uterus
by the contraction of the surrounding tissue, so as to project in the shape
of a conical tumor, and a slight indentation is  noticed- at the correspond-
ing point of the external uterine surface.   The close resemblance of the
paralyzed segment of the uterus to  a fibrous polypus, may easily induce
a mistake in the diagnosis,  and nothing but a minute examination of the
tissue can solve the question.   The affection always causes hemorrhage,
which lasts  for several weeks  after childbirth, and  proves fatal  by  the
consequent  exhaustion.   We have met with it  twice, once after abortion,
and once after parturition at the full period.1
  » Dr Betscbler, during his visit to Vienna in 1840, communicated a similar case to me as
having occurred at Breslau ; and there can be little doubt that Dr. Burkhardt (vide Berliner
Centralzeitung, x, if)  speaks of this condition, under the  title of acute fungus hamatodes
uteri  as of a new and  hitherto unknown cause of flooding after childbirth. 
230
DISEASES OF THE  UTERUS
  Lastly, Ave observe that the contraction and involution of the uterus
is more or less  permanently impaired by all  the  different puerperal in-
flammatory processes.

  § 2. Puerperal Inflammations.—Puerperal inflammations generally,
are in most cases of a very  complicated nature, and it is of extreme
scientific and practical importance that Ave should obtain a comprehen-
sive sketch of their anatomical bearings, as well as  an analysis and cor-
rect interpretation of the constituent phenomena.   If we consider puer-
peral inflammation of the uterus by itself, we find that it always appears
in the shape of an exudative process, affecting the raw exposed surface
of the uterus to which the placenta had been attached; in reference to
its original seat, it must therefore ahvays be  considered as endometritis.
We shall first have to examine into the characters of this affection, and
then proceed to investigate  other important puerperal diseases; after
which, we shall give a summary and an analysis of changes taking place
in organs and tissues that do not belong to the  original seat of disease,
and conclude  with a consideration  of the issues and  consequences of
primary and secondary puerperal affections.
  1. Puerperal endometritis.—This affection, as has already been ob-
served, is invariably an exudative  process;  but it offers the greatest
variety, both in reference to the plasticity of its product and to the con-
dition of the  diseased tissue, either  in individual cases or in entire epi-
demics.   The  series  is almost  endless, but we may consider genuine
uterine  croup on the one hand, and the so-called genuine putrescence of
the uterus on the other, as its extremes ; the  very fact of this great mul-
tiplicity of forms obliges us to limit  our descriptions to the most promi-
nent ones.
  In certain cases we find the internal surface of the uterus lined by  a
yelloAvish or greenish dense exudation,  of greater or less thickness and
extent,  either in small patches or investing the entire uterus, and either
firmly or loosely agglutinated, and occasionally partially or entirely de-
tached from the subjacent tissue, so  as to appear corrugated  or plicated.
The uterine mucous  membrane under the lymphatic coating is found red-
dened, tumefied,  and slightly softened; the  free parts are  discolored,
and invested with a dirty reddish  or brownish secretion, and with rem-
nants of the  deciduous membrane.  The exudation generally interpene-
trates  largely  the exposed  raw  tissue of the placental portion of the
uterus,  and causes it  to assume  a peculiar ulcerated appearance.   This
is uterine croup.
   In other cases the exuded matter is a gelatinous, purulent, dirty yellow,
loose  and easily detached layer,  beneath which the internal stratum of
uterine tissue  appears spongy, infiltrated, soft, and may  be easily de-
tached  in the  shape of a dirty yellowish-red, or partly greenish  and
brownish  pulp.  The internal surface of the uterus presents, in addition
to the lymphatic exudation, a glutinous secretion of a similar tinge.
   Again, the internal surface of the uterus may not present a trace of
coagulable lymph, but be invested by a purulent sanious and very dis-
colored exudation, beneath which  we find the uterine mucous membrane
infiltrated, in more  or less extensive  or circumscribed patches, Avith a 
AFTER  PARTURITION.
231
similar product; and it may either be easily removed in the shape of a
thin and much-discolored pulp, or it has already become detached, and
is mixed up with the contents of the uterus in the shape of friable dis-
colored flocculi.   In the place of the destroyed tissues, we occasionally
discover the products  of a reactive process, in the shape of a more or
less consistent sanio-purulent secondary exudation.
  Again, the internal layer of uterine tissue may be covered with a thin
opaque  or more dense, pale green or brownish, or dark chocolate or cof-
fee-colored product, beneath which it is  converted, to a greater or less
depth, into a loose, infiltrated, fetid pulp, of a similar tint.   This condi-
tion, which differs from ordinary sphacelus, has been termed putrescence
of the uterus.
  All these characters point to an exudative process, the peculiar nature
of which is fixed  by the form of its product, and  the condition of the
substratum, and especially by the state of fusion of the latter.  There
are numerous states.of transition between the forms described, and they
not unfrequently become complicated with one another in such a manner
that a process of a malignant nature follows one that is accompanied by
a secretion of plastic lymph.  As primary exudative processes, they are,
if possible, to be  distinguished  from similar secondary processes which
may occur in the course of the  disease in  consequence  of a secondary
affection of the blood, resulting from  inflammation of the veins or lym-
phatic vessels.
  As supplementary to the above, we have to examine those anomalies
presented by the uterus, Avhich are either direct reflexes of the processes
in question, or AArhich occur as accidental complications.
  To the former appertain paralysis of the uterine fibres and  impeded
involution of the uterus in various degrees.  According as the puerperal
affection attacks the uterus, sooner or  later after parturition  or with
more or less intensity, the womb is found  of  greater or less size, more
or less relaxed, collapsed, softened; and certain portions that  contain a
large amount of cellular tissue,  such as the lateral  edges and the cervix,
are infiltrated with a pale yellow, sero-gelatinous, or sero-purulent fluid.
The external surface of the fundus and body of the uterus not unfre-
quently exhibit numerous shallow depressions, that  are  caused by the
pressure of adjoining tympanitic coils of intestine.
  Among the accidental complications we reckon sanguineous engorge-
ment (apoplexy) of the neck of  the uterus, the superficial or  profound
lacerations and contusions which occur at this point, and in the  vaginal
segment; the lacerations being invested with exudation of a more or less
plastic character, whereas  the contused parts not unfrequently appear
in a state of gangrenous solution.  We have to mention the sloughs  of
greater or less dimensions,  which occur chiefly at the neck and vaginal
portion of the uterus, and  also in the vagina and the  external  genitals,
in company with malignant exudative processes.   These processes lead
to ulceration and gangrenous fusion of the tissues, very often inducing
extensive loss of substance in the external sexual organs and the neigh-
boring parts ; they render the prognosis of the individual case very un-
favorable, both on account  of the character of the  original affection,  as
well as of the consecutive destruction  which they entail. 
232
DISEASES OF THE  UTERUS
  Notwithstanding its close relation to the processes of exudation  and
fusion, which we have hitherto investigated,  we think it  necessary, on
account of the novelty and scientific interest attached to the question, to
devote a separate consideration to the dysenteric process occurring in
the uterus after childbirth, or puerperal uterine dysentery.
  The appearance presented by the inner surface of the  uterus  varies
according to the intensity  of the  disease.   In  one case  it is uneven,
nodulated, and invested by a dirty reddish, or broAvnish fetid secretion ; the
projecting parts of the mucous membrane are covered with a grayish-
yellow or firm greenish exudation, which here and there presents a fur-
furaceous exfoliation, and the subjacent mucous membrane itself is gene-
rally converted into a yellow slough ; the entire surface may thus in the
advanced degrees present an appearance exactly  resembling the impeti-
ginous condition of the intestine in dysentery.  The tissues of the uterus
are infiltrated throughout with serum, and, as  in the  intestine, we  find
the projections to be more particularly OAving to  an,accumulation of the
serous fluid  at certain points.   In another and more advanced degree,
which always runs a very rapid course, the  internal layer of the  uterus
is  found degenerated  into  a  brownish-black, friable, loose or detached
mass;   the  uterine cavity  contains a fetid  matter  resembling  coffee-
grounds ; the uterine tissue is flabby, pale, discolored, and more  or  less
infiltrated with the sanious  matter.   The process may thus  be said to
represent essentially, what we must call, if consistent in our terminology,
dysenteric putrescency of the uterus.
  The uterus in this case is always very large, or, in other words, its in-
volution is eminently retarded.
  It is  an additional  evidence of the nature of  this affection that it is
often seen combined with true dysentery, or  Avith the dysenteric process
on the mucous membrane of the colon.   The puerperal diseases occurring
during the prevalence of a dysenteric epidemic therefore deserve a more
careful examination and appreciation in  reference to  this point, both at
the bedside  and in the dead-room.
   These processes are scarcely ever isolated, but are  almost invariably
complicated with others.  The  degree of connection  existing  between
them and the complications, and between the complications themselves,
differs very  much;  Ave shall consider these points more fully, as we are
about to examine the more  important of these processes separately.
   2. Inflammation of the veins and lymphatics of the uterus.—Both, but
especially phlebitis, are important puerperal  diseases.
   Uterine phlebitis is generally a  primary affection, originating  in the
open mouths of the veins at the insertion of the placenta, and caused as
well by their laceration as by contact with the external atmosphere, Avith
the traumatic secretion of the part, and with  the product of exudation on
the internal surface of the uterus.   It is either confined to a small portion
of the veins, or it spreads over the greater part of the veins of the uterus
belonging to  the spermatic or uterine system of vessels.   In the latter
case, a secondary inflammation of the trunk of the spermatic vein, brought
on by coagulation of the blood, may on the one hand extend through the
vena cava to the right auricle, or on the other along the iliac and the 
AFTER  PARTURITION.
233
crural veins, to the cutaneous veins of the lower extremity ;  in this case
the symptoms of phlegmasia alba dolens are induced.
   The resulting products differ very much.   There  is no  doubt that
coagulable lymph is frequently secreted, which causes the venous parietes
to become agglutinated to  one another,  or  to a contracting  plug of
coagulum ; but in most cases pus is formed, which is variously discolored,
presents a dirty geenish,  or brownish, or chocolate-colored hue, with
a fetid odor, varies in density,  and is more or less sanious (septic  phle-
bitis).   In consequence of exacerbations, the same portions, or, if the
disease extends, consecutive sections of the uterine venous system, may
present various exudations at the same  time or in succession.
   Metrophlebitis undoubtedly sometimes occurs as the sole and primary
disease, but in the  vast majority of cases it is  complicated with exuda-
tive processes on the  internal surface of the  uterus.  This combination
commonly takes place from the  commencement, or the phlebitis  super-
venes upon and is induced by the exudative process ;  or, lastly, phlebitis
may exist for a  short period in  an isolated form as the primary disease,
and give rise to a single or to repeated exudative processes.
   We thus find  that the combined  processes  are closely related to one
another, in reference to their essential characters and the nature of their
product;  this and other points will become more apparent from the  de-
scription of the  chief anatomical symptoms which we are about to give.
   If incisions be made in various  directions from the point of insertion
of the placenta, to  the  lateral parietes  of the uterus and the adjoining
broad ligaments, a  large number of veins become  apparent, which  are
dilated and varicose, and filled with yellow or greenish-yellow viscid pus,
or even with chocolate-colored  sanies.   Their orifices at the placental
portion of the uterus, are either closed  up by loose pale coagula, or they
are covered over with an exudation which attaches itself to  the spongy
tissue of the raw surface, or, lastly, they are  exposed  so that their con-
tents exude on the  application  of a  slight pressure.  The  coats of  the
veins are relaxed  and  pale, the  lining  membrane is opaque, and dis-
colored by the contents of the vessels, and after  a protracted duration of
the  disease, it  appears tumefied,  thickened, partially gangrenous and
ichorous.  The tissue  surrounding the veins, and especially the  cellu-
lar tissue at  the lateral portions  of  the uterus,  is  infiltrated with a
yellow gelatinous or purulent matter, which is much discolored if the con-
tents of  the  veins  are  ichorous; the tissue is relaxed, soft,  friable, and
lacerable.   At different points there are  abscesses of greater or less di-
mensions, which not unfrequently burst internally, and discharge their
contents into the uterus.
   The internal surface of the uterus  presents purulent and  ichorous
exudations, the  products of primary or secondary  processes, or of both.
The tissues throughout are in a state of disorganization or  putrescence,
becoming dissolved in a manner analogous to the exuded product, and
being attacked from the various foci of destruction within the parietes of
the uterus themselves.   The discoloration advances as far as  the perito-
neum and the affection may, therefore,  be recognized by the  external
appearance, as well as by the general habit of the organ.   The fusion
occasionally predominates at one portion of the placental segment of the 
234               DISEASES  OF  THE UTERUS
uterus, involves the entire thickness of the parietes^ and causes the por-
tion to be detached, and to pass into the uterine cavity in the shape of a
pulpy, discolored, semifluid plug.
  Uterine  phlebitis often  runs  a rapid course,  with  intense typhoid
symptoms, proving fatal by uterine paralysis ; or it proceeds more slowly
under circumstances preventing a general infection of the blood, even
when the product is of a putrid character, and  then proves fatal by the
secondary destruction set up.
  Inflammation of the uterine lymphatics is, on the whole, less frequent
than phlebitis, and is generally complicated Avith the latter.   When  it
occurs, the lymphatics, and particularly those of the lateral and posterior
portions of the uterus, of the ovary, and the Fallopian tubes, become di-
lated and varicose, their coats pale and opaque, the lining membrane dull
and furred, and they contain  a yellow, yellowish-green, purulent fluid.
By these characters they may be traced into the neighboring  hypogas-
tric and lumbar plexuses, and into the associated glands, of the lympha-
tic system.
  Inflammation of the veins and lymphatics of the uterus is generally
the source of secondary occurrences, the so-called metastases, or lobular
foci of inflammation (lobulare  Entziindungsheerde), in the most various
tissues and organs, as well  as of exudative processes occurring  in serous
and mucous membranes during the later stages of puerperal disease.
  3. Inflammation of the peritoneum  (peritonitispuerperalis), viewed in
connection with puerperal inflammations of other serous membranes.—
Peritonitis is known as a very common puerperal disease; in rare cases
it actually constitutes the original (primary) puerperal exudative process,
and as such remains isolated.  It more  frequently simulates this form,
inasmuch as the processes with which it was originally complicated have
become retrograde  or  imperceptible,  or have actually  ceased after the
discharge of their products has been effected.   We most frequently find
it complicated with the puerperal affections already examined—viz. with
the exudative processes  occurring on  the internal  surface of the uterus,
with metrophlebitis and  inflammation of the uterine lymphatics.  The
pathogenetic relations of puerperal peritonitis, and especially its relations
to the last-mentioned puerperal processes, have  been much discussed, but
the subject has not as yet been adequately elucidated.
  We commence with a statement of  the anatomical signs presented by
puerperal peritonitis, in reference  to its extent  and terminations, the
quantity and quality of the effusion, and the coexistent degree of redden-
ing and vascular development.
  Puerperal  peritonitis is  not unfrequently limited to the  peritoneal
covering of the uterus and its appendages, when it presents more or less
redness, with more or less distinct congestion and a thin partial lymphatic
exudation, or a more dense and extensive layer of a viscid and consistent
or loose and  fluid secretion.
  We not only find the  peritoneal covering of the internal  sexual organs
attacked in this way, but also the peritoneum of the entire hypogastric
abdominal region.  The disease may even spread over the whole parietal
and intestinal peritoneal laminae; the symptoms, hoAvever, at the same
time predominating on the peritoneum of the internal sexual and adjoin-
ing organs. 
AFTER  PARTURITION.
235
  The entire peritoneum is often uniformly involved in the disease, not
only without any predominance of the symptoms in the  sexual organs,
but sometimes even with an apparent subordination of these symptoms.
  The products of these processes vary very much; they may be firm,
yellowish-gray concretions, loose, yellowish, membranous, grumous, gela-
tinous, or fibrinous coagula, which glue the intestines to one another, or
to the parietes of the abdomen, or they may be yellow and greenish-yellow,
thin,  sero-purulent or thick  purulent, dirty green and brownish, red,
hemorrhagic, thin, opaque, sanious effusions, the result of septic periton-
itis.   The product is sometimes very limited in amount, and may merely
present a thin covering of the internal sexual organs, or a few membranous
or fibrinous flocculi of coagulable lymph,  scattered through the abdominal
cavity ; but in the case of universal peritonitis it is generally extremely
copious, whatever the particular variety  of the product.
  The vascular development and redness is,  especially in  the last-named
cases, very  slight, and bears a marked disproportion to the  quantity of
the exudation.
  This fact in itself, and more particularly when examined in connection
with combined processes occurring in the uterus, and numerous analogies
and observations made at the bedside, justify the views Ave  are about to
propound, relative to the genesis of puerperal peritonitis and its connec-
tion with puerperal processes in the uterus.
  Puerperal peritonitis  not  unfrequently arises  by mere contiguity of
tissue, from an  exudative process  affecting the  internal  surface  of the
uterus, or from metrophlebitis.   It may remain confined to the internal
sexual organs, or become generally diffused, and this  occurs  the more
frequently the more the following circumstance prevails.
   The disease is often, and even generally, the result of a primary con-
dition of the blood of the female which predisposes to exudative processes,
and is totally distinct from the physiological tendencies of the blood during
pregnancy.  This proclivity is evidenced by exudative processes on the
mucous membrane of the uterus,  the  intestine, and various  serous mem-
branes, by exanthematic processes on the superficial integuments, by  a
revival of tubercular disease, &c.;  and both epidemic and endemic influences
and individual causes give it a peculiar character which becomes appa-
rent in the  product.
   Under such conditions  peritonitis will be the more liable to arise, the
more the peritoneum has suffered by the revolutions in its local relations
during parturition, by the excitement of the large organ, the uterus, which
it invests, and by the concurrent  disturbances  in the circulation; the
more exudative processes, or metrophlebitis, and various reactions conse-
quent upon uterine lesions occur in the vicinity of the peritoneum, and
especially in the uterine mucous membrane ; the more the peritoneum has
been previously affected by the contiguity of tissue to the  internal sexual
organs.                                          .                   ,
   In this case peritonitis  is a primary disease, and is either the nrst and
not unfrequently the  only puerperal affection, or it occurs, as is more'
frequently the case, concurrently with an exudative process of the uterine
mucous membrane, or soon becomes  associated with the latter;  it inva-
riably takes its origin in the above-mentioned  predisposition existing m
the blood. 
236
DISEASES  OF THE  UTERUS
  Like other exudative processes that occur simultaneously or consecu-
tively, we also find that peritonitis is often the result of a secondary dis-
organization of the blood, caused by the absorption of the products oi
exudation upon the external surface of the uterus, or by the direct ad-
mixture of the products of metrophlebitis with the blood.   In this case
it presents the characters of a secondary inflammation, and  is  commonly
complicated with exudative  processes  on  other  serous, synovial,  and
mucous  membranes, and with  capillary phlebitis in the most difierent
organs and  tissues, the so-called lobular infarctions (Lobular-lnlarcte)

  The products of the peritoneal inflammation in either case correspond
in character with those of the exudative processes affecting the internal
surface of the uterus and of metrophlebitis, whether they occur simulta-
neously,  or whether they precede the former.
  Puerperal peritonitis is  developed with more  or  less rapidity, and in
the majority of cases proves fatal by inducing abdominal paralysis; or it
leaves various morbid sequelae.  Those exudative processes are remark-
able which result from a very rapid  disorganization of the blood,  and
prove fatal within a few hours, or within  two to three days,and are ac-
companied by paralysis  and collapse, affecting the uterus immediately
after parturition, and by a sanguineous ill-looking effusion.
  Puerperal peritonitis, as may be gathered from the above, is almost
always remarkable for its very exudative, or croupy, character.
  4.  Puerperal inflammation of the ovaries and Fallopian tubes.—We
shall examine these affections when we speak of the diseases of the respec-
tive organs.   The first is  always complicated with  one of  the processes
that have been just discussed, and probably always with an exudative pro-
cess on the inner surface of the uterus; the affection of the Fallopian tubes
is invariably the result of an extension of the uterine exudative process.
   5. Phlegmasia alba dolens (sparganosis).—Various theories have been
formed in reference to this disease of the puerperal state, from its symp-
toms in  the living subject;  and very different views have been even pro-
pagated with regard to its anatomical relations.  The ancient and modern
dicta that were based upon anatomical investigations may  almost all be
viewed as the result of preconceived notions, and of examinations, under-
taken with a vieAV to establish favorite theories,  or conducted without the
necessary distinction  between  essential  and accidental  circumstances
being observed.   It is only of late that the subject has been examined in
 the dead body with an unprejudiced  and discriminating judgment, and
 that an  anatomical basis has been obtained, which, though it may not be
 applicable to all conditions that are included under the head of phlegma-
 sia alba dolens, and though it may not always have been properly inter-
 preted,  still appears to afford sufficient security.
    Two lesions seem to  be essentially connected with this  affection.  It
 either depends upon an inflammation of the veins of the inferior extremity,
 and especially of the crural vein, or upon an inflammation of the cellular
 tissue, which gives rise to the most various products.  The latter form is
 particularly likely to cause the characteristic symptoms which a so-called
 sero-lymphatic or sero-purulent product, i. e. fibrinous or purulent exuda-
 tion diluted by a large amount of serum, induces.  It is  characterized 
AFTER  PARTURITION.
237
by very slight reddening and vascularity, and must be  considered as an
exudative process.   In this shape it  often  extends to the crural fascia,
the neurilemma, the lymphatic vessels, and is sometimes complicated
with exudations in the synovial capsules of the knee and the hip-joint.
As we have already observed, it gives rise to the most various products,
and terminates accordingly in  tedious oedema, in sclerosis, suppurative
fusion, and  gangrenous destruction of the cellular tissue.  It  proceeds
from a primary or  secondary dyscrasia of the female, and is  in either
case generally combined with various other puerperal processes.  This
form of phlegmasia alba may, like the one that originates in phlebitis,
occur,  if similar causes prevail, independently of the puerperal  state, in
unmarried women and men ; and we  find  this to be particularly the case
as a result of exanthematic and typhous  processes, of the most various
exudative processes, of cholera, dysentery, inflammation of the lining
membrane of the vessels, of endocarditis, &c.   The disease may attack
the upper extremities and even the trunk, though in the puerperal state it
generally affects  the lower  extremities.   It occasionally proves fatal by
its  sequelae, but more frequently by the associated  puerperal processes.
   Crural phlebitis  generally passes from the uterine to the internal iliac
vein, and either  attacks  the deep-seated or superficial  veins,  or both.
An inflammation of the lymphatic vessels is often superadded.


 Summary  of the Anomalies in other Organs, accompanying the above-
                          described processes.

   Besides the changes which occur in the original seats of the puerperal
processes hitherto  examined, there are so many, important, and various
anomalies in other  organs and tissues, that it is not sufficient merely to
give  a supplementary account of the anatomical results, but  that as
copious  an explanation of them  as possible,  becomes necessary.   We
shall, in the first instance, describe and account for the general appear-
ance of the body, and the individual  organs, and then arrange the sepa-
rate morbid processes as much as  possible in groups, according to their
mutual resemblance.
   The dead subject presents  a remarkable disfiguration of the counte-
nance, tumefaction and discoloration of the external genitals, excoriation,
ulcerative destruction of  various  characters, with or  without laceration
of the perineum, various vaginal discharges, tympanitic distension of the
abdomen, a livid erythema of the common integument at different parts
of  the body, white  and often large coalescing  miliary  vesicles on  the
thorax and abdomen.  Yellow,  greenish, bilious, feculent, chocolate-
colored fluids escape from the mouth.                 #
   The abdomen presents, in most cases, even if the peritoneal inflamma-
tion has been slight or entirely absent, a  tympanitic distension of the in-
testines ; this symptom  is most developed in universal peritonitis;  the
 entire intestine is  then so  much  distended by gases, that it causes im-
pressions upon the  uterus, and forces the epigastric contents of the ab-
domen into the  cavity of the diaphragm,  and with the latter into the
thorax as far as the fourth and third ribs.  The firmer the  exuded (plastic) 
238
DISEASES OF THE  UTERUS
matter, the  more firmly the  intestinal  coils and  the other abdominal
organs are agglutinated to one another and  to neighboring organs.  The
coagulable lymph is chiefly contained in the lower segment of  the  ab-
dominal and pelvic cavity, but also in the lateral parts, of the abdomen,
between the  mesenteries and in the vicinity of the large epigastric viscera,
within spaces that have become more or less circumscribed by the adhe-
sions.   It not unfrequently causes, especially on the surface of the liver,
shallow depressions, and  gives to the superficial layer of this organ, if of
a purulent and sanious character, a greenish, and to the spleen  a black-
ish, tinge.   The reddening and  vascularity  of the peritoneum are gene-
rally inconsiderable; but most evident at  those parts, which are free
from pressure, and take  the form of narrower or broader  striae.  The
membranes of the intestinal canal are all tumefied, the interstitial cellu-
lar tissue infiltrated, the layers easily distinguishable and lacerable.  The
intestine generally  contains, in  addition  to a large  quantity of gas,  a
yellow, serous, feculent fluid,  which mounts up to the  duodenum and
stomach.  This fluid is in part the product of an exudative process that
occurs in the greater part of the intestinal mucous membrane, and which
we shall have occasion subsequently to examine more  closely.  The duo-
denum and the stomach may also be  found to contain a copious  amount
of yellowish-green or intensly  green biliary  fluid.
   We have here to advert briefly to two symptoms that occur during the
course of puerperal  peritonitis,  and which  not unfrequently coexist—
they are, vomiting of the biliary matters contained in  the duodenum and
the stomach, and of the sero-feculent  matters that rise  from the intestine,
and diarrhoea.  The former is to be explained by the paralysis of the
muscular coat of the intestine, caused  by the peritoneal exudative pro-
cess,  and the fixation of the  intestine by  plastic exudations;  it com-
mences at the duodenum and the stomach, the peritoneal covering of
which generally remains unattached.  The latter is caused by the exudative
process, and the  consequent  irritation of the intestinal muscular coat,
which forms a counterpoise to,  and  even counteracts, the  paralysis at
some points; it is the more frequent and the more considerable the less
marked the  paralyzing influence of the peritoneal affection is.
   Almost all organs appear in a state of relaxation, which is proportioned
to the primary or secondary dyscrasia of the blood, and to the extent in
which the blood has become deprived of its  fibrine by the fibrinous exu-
dations caused by inflammations of the peritoneum, the pleura,  &c.   It
is  owing to a moistening  or imbibition of the tissues with  the attenuated
serum of the blood, which easily exudes through the vascular coats, and
is  for the same reason coupled with pallor or discoloration, owing to the
coloring matter which adheres to the serum.   In the abdomen we find
that the kidneys and the liver are chiefly distinguished by the softening,
pallor, or  pale red discoloration, oedema and imbibition, relaxation and
friability of  their tissues.  In  the  thoracic cavity, the lungs are chiefly
affected by  these and  similar deviations; the  muscular  portion of the
heart, too, is, like the other muscles, and especially  those  that are in-
volved in the peritoneal inflammatory process, soft, pale, moist and
lacerable.  All the  serous membranes and  the lining membrane of the
vessels are infiltrated with serosity, and are more  or less  reddened  and 
AFTER  PARTURITION.
239
the serous cavities contain various quantities of a transuded, pale or dark-
red serum.   The brain  alone, as  in numerous  other  allied processes,
e.  g. in typhus, forms an exception, inasmuch as it appears denser and
harder, drier and paler, than usual.
   The spleen is very frequently, though not always, tumefied; it is so
particularly in  secondary disease of the blood, whether or not accom-
panied by the secondary processes (deposits), that we shall subsequently
have to notice.
   The lungs are reduced in size, and denser, in consequence of the up-
ward pressure exerted by the  contents of the abdomen; their inferior
lobes are of a dark purple color, and in a condition of passive hyperaemia.
   We now proceed to enumerate the separate morbid  processes in  the
different organs, and to point out their relations to the original puerperal
disease.
   Our first attention is  due to the exudative  processes on the various
mucous and  serous membranes.  That  affecting the intestinal mucous
membrane is of particular  importance.   The entire tract  is generally
involved; it  is  but  slightly reddened,  and commonly  exhibits a thin,
watery,  serous, or viscid gelatinous,  or gelatino-purulent or genuine
purulent product; the tissue fuses,  and the  submucous  cellular tissue is
more or less infiltrated.  In this manner the diarrhoeas of the puerperal
state  are established.  The exudation  is rarely of  a firm, fibrinous, or
croupy nature,  but most commonly its  serous character predominates,
and this is the more the case the larger or more fibrinous  the product,
resulting from the coexistent attack of peritonitis.   In  certain cases the
process that takes place on the mucous membrane of the colon assumes
a dysenteric type, and as in the  above-named forms, corresponds to the
exudation upon the internal surface of the uterus or to the product of
metrophlebitis.  Similar processes, though  generally accompanied with
a coagulable  product, are occasionally discovered upon the  mucous mem-
brane of the stomach, the oesophagus, and the  bladder,  and in the lungs
in the  shape  of (partial) aphthous pneumonia;  this is chiefly the case
when the blood  has not been exhausted  of its fibrine.
   Among the exudative processes that take place on serous membranes,
the most frequent, after' that occurring on the peritoneum, is pleuritis,
which is often coexistent with peritonitis ; pericarditis is of less frequent
occurrence.   We also meet with exudations in the synovial bursae,  and
especially in  that of  the knee-joint, the  sterno-clavicular  and humoral
articulations, and, lastly, in the capsule of the humor aqueus.   The exu-
dations are generally very copious,  fibrinous, and purulent.   A thin  soft
exudation is often found upon the  dura mater, accompanied by a slight
reddening of the latter.
   All these processes may  be  variously combined,  and they are  depen-
dent upon the  primary  or  secondary disorganization of the blood,  and
especially upon  that caused by the absorption of pus in  metrophlebitis. _
   Next in order come the processes dependent upon secondary phlebitis
of the larger veins, and of the capillary venous systems  of various organs
and tissues.                                 ...           .  .
   The former are generally developed m the vicinity ot  the original mor-
bid affection,  as in the plexus pampiniformis, the trunk of the internal 
240
DISEASES OF THE  UTERUS
spermatic A-ein, the internal iliac and crural veins; though they frequently,
too, are generated at a distance, as in the cerebral sinuses and the pul-
monary artery.   These give  rise to the so-called  metastases  or lobular
abscesses, Avhich we shall now proceed to examine.
  We often find larger or smaller circumscribed spots in the most various
organs and tissues; the dark-red points of congestion, or small accumula-
tions of pus or sanies, which we have repeatedly adverted to.   They are
remarkably frequent and numerous in the organs of sanguification, espe-
cially in the lungs and the spleen; they are next seen  in the kidneys, and
more rarely in the liver; they are occasionally met Avith in the brain, in
the thyroid and parotid glands ; in all muscles, particularly in the heart;
in fibrous tissues, as in the dura mater and the periosteum. Again, they are
very common in the mucous tissue, especially of the bladder and the in-
testines ; they occur throughout the cellular tissue, but they seem to pre-
dominate in the cellular tissue of the  extremities, of the mediastina, of
the neck, the iliac muscles, and the intestines and stomach.
  We have already demonstrated that these processes are either genuine
exudative processes, or  that  they consist  in a coagulation of the blood
within  the capillaries (capillary phlebitis).   In the latter case  the coagu-
lum fuses in a manner corresponding to the disease of the  blood, and to
the deleterious matter absorbed into the blood, and forms a purulent sani-
ous fluid  or gangrenous pulp  (metastasis puerperalis septica).
  They may probably be invariably considered as the result of a secon-
dary infection of  the blood, of a poisoning of the blood by the introduc-
tion of some product from the original nidus of disease, and particularly
of venous pus and sanies in metrophlebitis.  They consequently always
give rise  to purulent and sanious products, and terminate fatally as capil-
lary phlebitis.  They enter into various combinations with one  another,
and with the exudative processes occurring upon serous and mucous mem-
branes.  Owing to their position  at the surface of the organs, we always
find that pleurisy supervenes upon their  occurrence  in the  lungs, and
peritonitis upon their deposition in the spleen.
  A black softening of the mucous membrane of the fundus ventriculi,
or of the oesophagus, or of both at the same time, which is indicated dur-
ing life by the vomiting of black coffee-grounds-like matter, is of frequent
occurrence.   It not rarely reaches that degree of intensity, that the fun-
dus of  the stomach, and sometimes the diaphragm also, and the oesopha-
gus, with the adjoining cellular tissue and mediastinum, are  ruptured, and
the fluid  that would have been evacuated by the mouth is effused into the
abdominal or thoracic (especially the  left) cavities.
  After  difficult  labor, the cartilages of  the  pelvic  synchondroses are
liable to inflammation, in consequence of the traction  exerted upon them,
and if the blood has assumed a septic  constitution, the inflammation
may terminate in gangrenous fusion of the cartilage, the latter beino- con-
verted  into a dirty brown and very much discolored fluid, contained within
the investing ligamentous tissue.
  The blood contained in the cavities and larger vessels presents various
and more or less evident changes.  Its fibrine may be converted into con-
sistent, viscid, greenish-white,  or yellowish coagula; or after  previous
extensive discharges of fibrine it may be attenuated, watery,  exuding 
AFTER  PARTURITION.
241
thiough the coats of the vessels and the adjoining tissues, and presenting
but feAv and trifling, gelatinous, soft coagula.  Again, after previous puru-
lent or sanious absorption, it is of a dirty brown-red or chocolate color,
ATiscid, glutinous, depositing  dirty Avhite, opaque, fibrinous concretions,
Avhich in the heart form numerous ramifications, or presenting dark-red
coagula,  Avhich are paler at the surface, and fusible.  Lastly, if the dis-
ease has  run a rapid course, the blood is much reduced in quantity, and
even Avithout defibrination  having taken place, it is attenuated and dis-
colored, and transudes all the tissues.  The fibrine is sometimes found
deposited on the  valves of the heart in the shape of vegetations, without
the demonstrable occurrence of previous pericarditis.   The severe jaun-
dice affecting women during the puerperal state is ahvays dependent upon
pyaemia,  and never upon an appreciable derangement of the liver.
   The formation  of bone occasionally noticed on the external and internal
table of the skull after parturition is, as Ave have already observed, in no
connection whatever with the puerperal process.
   6.  Termination and consequence of the puerperal processes.—We con-
fine ourselves at  present to an account of those terminations  and  conse-
quences  of  the  fundamental  puerperal  processes, Avhich are not to be
inferred  from the preArious remarks.
   Puerperal peritonitis generally terminates in the same manner as ordi-
nary peritonitis ; we notice as particularly important the unfavorable ter-
minations in suppuration—phthisis—of the peritoneum and  the adjoining
tissues (ulcerative perforations of the diaphragm, the abdominal parietes,
the intestines, the bladder, the vagina, &c), and in peritoneal tuberculosis.
The exudations upon the internal sexual organs may become converted
into cellular  tissue, and  by fixing the tubes in an unfavorable position,
even Avithout  occlusion of the fimbriated extremity, cause sterility.
   The exudative processes occurring on the internal surface of the uterus,
as well as the exudation in  the  uterine parenchyma accompanying the
former and metrophlebitis, not unfrequently degenerate into suppuration
of the uterus, and the consequent purulent and sanious abscesses, extend-
ing chiefly from the point of insertion of the placenta in  various direc-
tions, may discharge themselves into the peritoneal cavity.   The affection
generally runs its course as acute uterine phthisis.
   A very remarkable  and important result of the exudative processes on
the internal surface of the uterus is  tabes of the uterus, which is  mani-
fested by extreme brittleness and friability  of the uterine fibre.  The
uterus very rarely attains such a degree  of involution as to resume the
size of the unimpregnated organ ; it generally remains  considerably en-
larged, of the size of a duck's egg or a man's fist; its tissue at the same
time is porous, of a pale red, and at some parts of a slate color;  the in-
sertion of  the placenta continues visible, by  the relaxation of the tissue
and the irregularity of the inner surface, or the mucous membrane is at
this place  invested by a yellow or  yelloAvish-white  ashy  substance, the
remains  of  the exudation, and generally  presents a retiform appearance.
   Metrophlebitis, by the suppuration of the coats of the veins, gives rise
to the formation of abscesses in  the  uterine parenchyma,  which not un-
frequently anastomose at various points, and thus form branched sinuses.
The disease is Very persistent if the uterus passes into a state of  maras-
  VOL. II.                          16 
242
ABNORMITIES  OF
mus, and if it maintains dirty brown hemorrhagic and fetid exudations on
the internal surface of the uterus.


         SECT. III.—ABNORMITIES OF THE FALLOPIAN TUBES.

   § 1. Befect.—The  tube may be absent on either side if there is a cor-
responding defect of one-half of the uterus, but this certainly is not al-
ways the case, inasmuch as it is not only often present when there is not
eAren a trace of a uterine rudiment,  but as it may exist in the shape of a
solitary coiled tubercle even  when the ovary is Avanting.
   In many cases the Fallopian tube may be imperfectly  developed, its
coat thin, its  parenchyma impoverished,  and its passage narroAved ; or
the uterus being normal, it may merely appear as an excrescence of the
former, terminating blindly above the uterine horn, or it may be inserted
either  at its normal  place, or elseAvhere,  Avithout presenting an  open
channel.
  When a Fallopian tube is absent, the  peritoneum occasionally presents
a fringed process, in imitation of the morsus diaboli.

  § 2. Anomalies of Calibre.—These consist  in  dilatation  or  contrac-
tion of the Fallopian tube ; in the latter case obliteration may result.
  The  former is very commonly the consequence of a catarrh of the tube
owing to retention of  the mucous secretion from contraction, obliteration
or obturation of the orifices;  it may degenerate into dropsy of the tube,
an affection of which we  shall say more at  a future period.
  The  latter consists—independent of the natural contraction of the tube
in the decline of life—chiefly in a  diminution of the passages  by tume-
faction of the  mucous  membrane, or in obstruction of the same by mucus.
The  contraction may pass  into complete  closure or obliteration of the
tubes ;  it chiefly affects the uterine orifice in consequence of catarrh ; the
fimbriated extremity is often  closed up by cellular formations, or organ-
ized peritoneal exudation (atresia tubae).   The imperforate condition of
the Fallopian tubes is of importance in regard to sterility.

   §  3.  Anomalies  of Position  and Birection.—Under  this head we
reckon  the very unusual congenital irregularities in the entrance of the
tube into the uterus, Avhether  communicating with the cavity of the latter
or terminating in its tissue blindly.
  Among the acquired abnormities the deflections and curvatures of the
tubes become  the more important, the  more the unattached end of the
tube is turned away  from the ovary and fixed in  its abnormal  position
by the products of peritoneal inflammation.  It is found variously agglu-
tinated to the neighboring tissues, and is particularly apt to  become re-
verted upon and fixed to the  posterior surface of the broad ligament the
ovary, and the uterus.
   In consequence of chronic  catarrh, or tubercular disease of its mucous
membrane, accompanied by  hypertrophy or  thickening of its parietes,
the Fallopian  tube is apt to assume a serpentine tortuous course.  Or if"
the ovary  enlarges, it maybe  extended to an unusual length,'and its 
THE  FALLOPIAN  TUBES.
243
coats thinned;  and if it happens to wind round the former, it is much
stretched.
  The tube has, like the ovary, occasionally been found in the abdominal
ring, within an inguinal hernia.

  § 4. Biseases of the Tissues.
  1. Hyperaemia, hemorrhage.—Hyperaemia of the Fallopian tube is
almost always a symptom of general congestion of the sexual organs, and
especially of the uterus.   In rare cases, hoAvever, the hyperaemia of  the
tube predominates, and may lead to hemorrhage of the  tube, in which
case a larger or smaller  quantity of blood is  effused into the cavity of
the peritoneum.
  We have twice had occasion to observe the  occurrence  of such hemor-
rhage in the course of abdominal typhus; the left tube was distended, its
mucous membrane of a purple tint, and congested.   We have once seen
it in the body of a female who was  attacked, three  days previous to  her
confinement, Avith pleuritis and  hepatitis, and in the fourth  instance it
was associated  with retroversion of the uterus.   Barlow has met with this
condition  in purpura, in consequence of or connected with abortion ;  and
Brodie has observed it in a case of retention of menses in the uterus, OAving
to occlusion.
   2.  Inflammation,  a.  Catarrhal inflammation.—Chronic catarrh, or
blennorrhoea of the Fallopian tube, is a very common disease; it is  fre-
quently a residue of a puerperal affection of the mucous membrane of the
tube ; or the catarrh may have extended from the vagina and uterus to
this point, and is coexistent with vaginal and uterine catarrh, or persists
after the  cessation of the latter.
   At the same time the  tube is variously dilated, its course tortuous, its
coats thickened ; the mucous membrane is tumefied, purple, slate-colored
or  of a blackish-blue  tint;  the  passage contains a viscid, transparent,
milky white or creamy, or a bluish-gray, or yelloAv, purulent mucus.
   Catarrh of the Fallopian tube, by spreading to the fimbriated extremity
gives rise to peritoneal inflammation in the vicinity of the  orifice,  and
thus the free termination may become adherent to the neighboring tissues
and be closed up, whilst the uterine orifice is obstructed and occluded by
the catarrhal tumefaction of the  mucous membrane.  Catarrhal  inflam-
mation in this manner induces sterility.
   The chief seat of catarrh is the external distended portion of the chan-
nel, and  it is here that we find  the greatest accumulation of blennor-
rhoic secretion.
   Under  the above-mentioned  condition, viz. occlusion of the  orifices,
catarrh of the tube is very often converted  into dropsy  of  the  tube, a
condition  similar to that Avhich we have already become acquainted Avith
in various other mucous  channels and  cavities.   In consequence of the
accumulation of secretion from obstruction of the orifices, the tube, espe-
cially towards its fimbriated extremity, becomes so  much distended, that
that which before represented a  tortuous  or bent  channel, is now con-
verted into a simple  sac.   At other times, several saccular dilatations
form between the separate angles and the projecting duplicatures of the
tubal parietes,  and give  rise to an imperfectly loculated pouch, which, 
241
ABNORMITIES  OF
as in the former case, may contain blennorrhoic mucus,  a puriform se-
cretion, a true purulent inflammatory product, or, if the  mucous  mem-
brane has become  altered, fluids of another description.  It is to be ob-
served, that as the dilatation proceeds, the texture of the mucous mem-
brane is changed, and the latter is converted into  a  serous membrane ;
its  secretion may be a  thin, Avatery, serous, or albuminous  synovoid,
colorless liquid, giA'ing the tube the appearance  of a transparent sero-
fibrous bladder ; or it may be variously colored, yellowish, brown, black-
ish-green, chocolate-colored, inky, and more  thick and flocculent, con-
sisting in part of inflammatory products  on the internal surface of the
membrane.
  The hydropic Fallopian  tube not unfrequently attains the size of a
duck's or goose's egg, or even of a man's fist; although not a usual oc-
currence, still it is satisfactorily proved that the contents  are sometimes
discharged into the uterus, and thus  carried off.
  In extremely rare instances chronic catarrh of the Fallopian tube be-
comes  acute, and  passes into suppuration;  its contents may then be
either poured into  a cavity of  the  peritoneum, which  has been  circum-
scribed by adhesive inflammation, or into the perforated intestine, which
has been preAriously agglutinated to the tube.
  b. Exudative processes.—An exudative process scarcely occurs on the
mucous membrane of the Fallopian tube, except in combination  Avith a
similar condition of the  internal uterine surface after childbirth.  The
tubes are tumefied and infiltrated; their mucous membrane is variously
reddened, discolored, excoriated, softened, and everted at the fimbriated
extremity ; the  passage of the tube is dilated, especially at its outer end,
and filled with various products, purulent and sanious fluids, and in uterine
croup Avith coagulable lymph, assuming the shape of a tubular concre-
tion.   The exudative process has extended from the uterus to the tube.
  3. Adventitious growths,   a. Cysts.—Serous  cysts  are very often
formed at the  fimbriated extremity  of the tubes, and in its vicinity;
and they are generally attached by a  pedicle, which sometimes attains a
considerable length.  They scarcely  ever become larger than a bean or
hazel-nut.
   b. Fibroid tumors.—These are  not frequent; they are rarely larger
than a pea,  and occupy the parenchyma of the tube in the shape of round
or discoid tumors.
   c. Tubercle.—Tubercle of the Fallopian tubes (Fallopian mucous mem-
brane) is generally associated with uterine tubercle ; but it is remarkable
that it sometimes occurs  independently of the latter, or in a condition of
higher development.  It therefore folloAvs that in  many cases of tuber-
cular affection of the internal sexual organs, the  mucous membrane of
the Fallopian tube is the primary seat of disease.
   Tubercle of the tube is almost ahvays presented to us in the dead sub-
ject, in the  shape of tubercular infiltration and  complete disorganization
of  the mucous membrane ; the latter being converted into a softened
purulent layer  of yellowish-white, cheesy,  lardaceous matter, which is
cracked and friable, and chokes up the passage.   The tube is more or
less swollen, its course tortuous,  it is hard to the touch, and its parenchy-
matous coat thickened,  and converted into a  dense  lardaceous  tissue. 
THE  OVARIES.
245
 The fimbriated extremity presents a very peculiar appearance; the mu-
 cous membrane, Avhich is infiltrated with tubercular matter, being pushed
 out in the shape of a cauliflower excrescence, and everted upon the peri-
 toneum.
   Opportunities are very  rarely afforded of observing the disease at
 its commencement, which occurs in the shape of a deposit of crude, gray,
 discrete,  or agglomerated tubercular  granulations.  In  the above-de-
 scribed shape, it must doubtless be vieAved as the result  of a tumultuous
 localization of the general disease, occurring under symptoms of con-
 gestive inflammation.   The remarks made in reference to uterine tubercle
 apply to this affection.
   d.  Carcinoma.—Except when involved in cancer of  the  peritoneum,
 the tube is not affected by this disease ;  and even  an extension  from
 the uterus  or  other adjoining tissues by mere contiguity,  after pseudo-
 membranous attachments have been effected, is very  rare.   Still I have
 noticed one case of ovarian cancer, in Avhich the tubes,  without being
 agglutinated to the former, were thoroughly diseased ; the parietes were
 very much  thickened,  callous,  contracted in their long diameter,  and
 curled up.


              SECT. IV.—ABNORMITIES OF THE  OVARIES.

   § 1. Befect of Formation.—It is very unusual for one of  the ovaries
 to be wanting, if the sexual apparatus is otherwise  normal.
   The ovaries often appear, together Avith the other portions of the sexual
 organs, in a state of imperfect development,  and small;  and, on account
 of the depth at which the Graafian follicles are  placed,  of uniform den-
 sity and hardness, and with an even and smooth  surface.

   § 2. Beviations of Size.—We find various enlargements occurring in
 the ovaries, Avhich form a contrast with the  just-mentioned smallness of
 the ovaries  and their diminution at the decline of life;  the  latter affec-
 tion only comes within the domains of pathology if it occurs prematurely.
 We shall haA'e occasion to notice them all under the head of textural dis-
 ease, and therefore do  not here enter into a more minute examination of
 the subject.  We  here merely allude to  that form  of  ovarian dropsy
 which results from the excessive development or hypertrophy of one or
 more Graafian vesicles, as a subject coming  under  the above denomina-
 tion ; but it will be more practical to consider it  fully Avhen we speak of
 the formation of ovarian cysts.

  § 3.  Biseases of the Tissues.—These diseases affect either the cellulo-
 fibrous substance (stroma)  and the fibrous  capsule  of the ovary, or  the
 follicles, or both  together, as Ave shall  have  occasion to explain in the
subsequent sections that relate more particularly to  this point.  We con-
fine ourselves to the most important and  conspicuous affections  of the
follicles and their contents.
  1. Hyperaemia, Apoplexy.—Hyperaemia of the  ovary, affecting both
its stroma and the external layer of  the follicle, occurs physiologically
in menstruation;  but  it also accompanies numerous pathological pro- 
246
ABNORMITIES OF
cesses in the sexual apparatus, and is sometimes permanent.   Its cha-
racters  are  tumefaction  of the  ovary,  softening of  its tissue, vascu-
larity,  and darker color; permanent hyperaemia gives rise to a gradual
increase of  size, to hypertrophy  of the  stroma, and enlargement of the
ovary.
  Hyperaemia affecting the more developed follicles that are seated at
the surface  of the  ovary often induces effusion of blood into  the cavity
of the follicle or apoplexy.  One or more cysts, varying in size from a
pea to a hazel-nut, are found in  the ovary; they project  more  or less
above its surface, after  having perforated the fibrous sheath of the OArary,
and are at once recognized by their  contents being visible through the
parietes of the follicle.  If seen shortly after the occurrence of extrava-
sation, they are tense: but more commonly a certain  amount of coagu-
lation has been effected in their contents, and they then appear slightly
collapsed, and present  fluctuation.   They  now  contain a dark-red
loose coagulum, which is invested by a Avhite  or  colored  fibrinous coa-
gulum  varying  in thickness.   In the  course of time the  coagulum
assumes a  rusty or  yellow  color, is  converted  into  a pulp which
gradually becomes inspissated, and yields the above-mentioned fibrinous
coagulum and serosity, the latter being in its turn removed by exosmose
and absorption.   The entire cyst contracts, retaining traces of the origi-
nal lining coagulum of fibrine  and of its yellow deposit,  and, perhaps,
also, a yellow, indurated,  friable, chalky residue of the coagulated blood;
it may become reduced to less than the  normal size of the follicle, and
from drawing in the fibrous sheath of the ovary, cause the appearance of
a cicatrix.  The contents and parietes of the apoplectic cyst consequently
present an appearance which varies according to the length of time that
has elapsed.   We very often find cysts of different dates in one or both
ovaries.
  It is evident that this effusion  of blood must induce a  destruction of
the germ, and, at last, cause an entire obliteration of  the follicle.  The
cicatrix naturally always presents a greater  or less resemblance to the
corpus luteum.  Although the amount of effusion is often very consider-
able, rupture of the follicle and hemorrhage into the peritoneal cavity
is of very rare occurrence.
  The most common cause of this affection is excessive menstrual con-
gestion, and it undoubtedly comes within the  sphere of pathological  in-
quiry (vide  Negrier).
  2. Inflammation.—Inflammation occurring in the ovary, independently
of the  puerperal state, is limited tp the follicles.  The coats of a follicle
are occasionally found injected, reddened and  softened, and friable ; the
contents are opaque, flocculent, reddened by an admixture of  blood, and
not unfrequently purulent.  Each of these processes, even in its slightest
form, is followed by a  destruction of the germ  by means of the exuda-
tion ; obliteration of the follicle soon ensues, and the first impulse is thus
given to its  conversion into a common serous cyst, which in its turn may
grow into ovarian dropsy.
  On the other hand, inflammation resulting from  childbirth, puerperal
inflammation, involves the entire ovary,  though probably in  the first
instance the stroma only; it is this that  generally gives rise  to the sup-
puration and abscess of the  ovary noticed by ancient and modern ob- 
THE  OVARIES.
247
servers.   It not only varies much in intensity, but, like  the  other puer-
peral processes, in kind also ;  this  is  particularly evidenced  by the
product and the state  of the tissues.   According to  the  manner in
Avhich it is complicated with  other  puerperal affections, it plays the
chief, or only a secondary part, as will become apparent from the follow-
ing remarks.
  The ovary may be swollen to the size of a hen's, duck's, or goose's egg,
presenting various discolorations, and being at the same time  collapsed
and pulpy, its tissue distended by a dirty yellowish-broAvn, brownish-
green, chocolate-colored fluid,  or converted into a fetid pulp ;  this is
putrescence of the ovary.
  Or the  ovary may present a pale greenish, or yellowish, or reddish
gelatinous viscid product, which is deposited in the stroma in large quan-
tities ; the latter being at the  same  time friable or semi-fluid, the fol-
licles  tumid, their coats swollen, and  their contents opaque  and floccu-
lent.   The ovary is at the same time enlarged and tense, as in the former
case.
  Again, the deposit may be serous (of  a pale yellow or reddish color)
or fibrinous (of a yelloAvish-white color),  and fusible ; filling  the tissues,
and causing the follicles to present an opaque appearance.  The tissue
of the ovary and the  coats of the follicles are congested and more or less
reddened, and both are softened and  friable.
  Again, the congested stroma of a moderately  tumefied ovary may be
infiltrated with a flocculent serosity, which is rendered opaque by plastic
exudation.
  In  all these cases the parenchyma  of the ovary is more or less ecchy-
mosed ; its sheath presents exudations of various kinds, under which dif-
ferently-colored, spotted, or striated suffusions are found; the  tissue at
the same time being softened, and extremely friable.
  These are the chief varieties and degrees of puerperal inflammation of
the ovaries ; they enter into complications with other puerperal processes,
and especially with endometritis  and peritonitis, and  give  rise  to the
same  products ; they differ, hoAvever, in intensity, and the inflammation
of the ovary may  either be the  predominating  disease, or, as is com-
monly the case, the subordinate or partial symptom of an extensive exu-
dative process of  the uterine or tubal mucous membrane, of the tissue
of the uterus, or the adjoining accumulations of cellular tissue  or of the
peritoneum.
  We have, lastly,  to allude to the condition presented by the ovaries in
puerperal exudative disease, Avhen they  are  not  themselves  involved in
the latter process;  like the other  tissues in the vicinity of the seat of
disease, they are infiltrated with serum, softened, flabby, pale, and friable.
  Exudative processes either affect one, or, more frequently, both ovaries
at the same time, though generally not in the same  degree.  They may
run a very rapid course, sometimes even assuming such violence as to in-
duce a spontaneous rupture of the ovary ; they prove fatal by the inten-
sity of the general disease; or by the  exudative processes with which
they are complicated ; or  they may terminate, after a  slower progress,
in suppuration (phthisis) of the ovary.   In the case of recovery, sterility
is entailed upon the affected ovary, in consequence of destruction of the
germs and obliteration of the follicles. 
248
ABNORMITIES  OF
   Suppuration either commences at separate points  which  gradually
coalesce, or it  is set up equally throughout.  The parenchyma  of the
ovary is by degrees consumed, and the organ converted into a purulent
cyst, which sometimes attains a very considerable size.
   The abscess itself is sometimes borne for a long time without marked
symptoms, and nature does her utmost to  prevent a free discharge  of it
into the peritoneal cavity;  for adhesions are formed between the ovary
and the adjoining viscera,  either in consequence of peritonitis  having
been  combined  with the inflammation of the ovary, or from circum-
scribed inflammations of the peritoneum having been set up in the course
of the ovarian disease.  Thus the ovary may become agglutinated to the
broad ligaments, to the pelvic parietes, the uterus, the bladder,  or the
rectum and the sigmoid flexure, to the caecum and the vermiform process
and the small  intestine ; and it is generally attached to several of these
viscera at  the  same time.   When at last the suppurative process has
eaten away the fibro-serous investment of the  ovary, and caused its
rupture, the discharge follows, from a yielding of the  adhesions,  into a
circumscribed cavity ; neAv partial inflammatory attacks of the peritoneum
ensue, or the pus meets Avith an organ which presents firm attachments.
In the former  case, the circumscribed processes  not unfrequently  pass
into universal peritonitis, or this is  induced by an extravasation  of the
pus through the relaxed adhesions.   Again, in either of these cases, the
suppuration may extend to the adjoining viscera, and the contents of
the abscess be  discharged  outwards, indirectly through a circumscribed
peritoneal  sac, or  directly in the hypogastric or umbilical regions ; or
into a portion  of the intestine, into the bladder or vagina.   Suppuration
occasionally takes, place in  the pelvic cellular tissue investing the  iliac
muscle; such abscesses  pass through the femoral ring or through the
ischiatic notch, and accordingly make their appearance on the thigh or
the nates.  They may thus  discharge themselves at a  considerable dis-
tance from the original nidus.
   3. Morbid growths, a. Cysts.—In no part  of the body are cysts so
frequent, or so various as in the ovary, in  the peritoneum, in the neigh-
borhood of the internal  sexual organs, or in  the subperitoneal cellular
tissue ; as,  for instance, betAveen the laminae of the broad ligaments, and
at the fimbriated extremities of the tubes.   Moreover, the size attained
by the ovarian cysts is extraordinary.  It is more practical  to consider
all the different cysts at  this place,  though Ave shall parenthetically indi-
cate the position they occupy in morbid anatomy, and have to revert to
them in the sequel.   At the bedside the term ovarian dropsy is equally
applied to  all cysts,  provided they fluctuate.   We commence Avith the
simple formations, and pass on to  those which, in reference to original
development, structure, groAvth, pathological importance,  and  contents,
are more complicated.
   «. Simple cysts.—They  are of very common  occurrence.   There are
either one or several unilocular cysts in  the  ovary; at times they are
even so numerous, that the ovary appears converted into an aggregation
of  cysts.   They are placed near one another,  each one  beino-formed
from the stroma, independently of the other, and they have a rounded form.
If they enlarge, they come into mutual contact, their parietes adhere to 
THE  OVARIES.
249
 one another, and they are flattened by reciprocal pressure; the impres-
 sion may thus arise that  several have, in the manner of the compound
 cysts, been formed within the parietes of the same matrix.  They attain a
 considerable size, rarely, however, exceeding that of a man's head.  In
 this case the  solitary cyst, or  one of several  cysts, undergoes extreme
 deArelopment,  Avhilst the remainder continue undeveloped.   They gene-
 rally have delicate sero-fibrous parietes, and may contain a colorless, or
 pale yellowish or greenish, serous, or a more consistent yelloAv, brownish,
 colloid substance,  or an  opaque  chocolate-colored or inky fluid.  In
 many cases they are undoubtedly formed from the Graafian  follicles; and
 it appears that an inflammatory process is particularly liable to give the
 first impulse to this metamorphosis.   They are  probably, however, as
 often new formations from the beginning ; and this is the more likely in
 those cases in Avhich their number exceeds the average number of Graa-
 fian follicles.   Allied to them are the  adipose  cysts  of  the ovaries;
 these  we shall, however, discuss at a later period, on  account of their
 numerous peculiarities.
   (3.  Compound cysts.—They occur  in the two  forms  described by
 Hodgkin.  In the  one, new cysts  are  formed in the coats of an older
 cyst, and although projecting into the  cavity of the latter, they do not
 actually grow into it; the oftener this process  is repeated, the more
 complicated the morbid product becomes.  In the other, an endogenous
 generation of cysts is effected, cysts being formed upon  the internal sur-
 face of another cyst, and being either sessile or pediculated; the matrix
 is sometimes entirely filled, the cysts  discharge  themselves into  it and
 become adherent to it, and subsequently a third  order of cysts may be
 formed Avithin them, &c.  The tAvo forms are often seen  in  the same
 ad\rentitious growth.
   These cysts are  capable of very extensiAre development;  to them and
 to the following variety the  large  encysted ovarian dropsies are  due.
 The separate  cells  or loculi contain the above-mentioned different sub-
 stances, and their parietes, especially those of older cysts, are generally
 of considerable thickness, and of dense texture.   They,  too, may proba-
 bly in the first instance be developed  from a  Graafian vesicle as simple
 cysts, or they may  form as adventitious growths ; the remaining substance
 of the ovary is spread out at the base of the cyst; it is, as it were, thrown
 open, and its tissue condensed.
   y. A third form, which very much resembles,  and is closely allied to,
 the last, is of  a cancerous nature, and belongs  to the areolar variety of
 carcinoma.  In the shape which we are about to describe, it  rarely occurs
 anywhere but  in the ovary.  It is  an accumulation of numerous fibrous
 sacs, Avhich contain various substances,  but for the most part a glutinous,
 viscid matter.   They diminish in size  from the  circumference towards
 the interior, and especially towards the  base  of  the morbid groAvth; so
that the latter represents a condensed alveolar mass, the alveoli or folli-
cles of which  consist of a white, shining, fibrous tissue, and contain  a
colorless or grayish, yellowish, yelloAvish-green, or reddish viscid gelatine.
We have here an areolar cancer, the peripheral  follicles of which are
converted into large  sacs.  This species of ovarian dropsy, which, for
the sake of distinction from the other varieties, Ave term  alveolar dropsy, 
250
ABNORMITIES  OF
is proved to be malignant, not only by its being accompanied by  avcII-
marked cachexia, but also by its complication Avith  cancer (especially of
the medullary variety) in the same  organ,  and Avith  other varieties of
cancer in other organs, as the peritoneum, or the stomach, and moreoArer
by its complication with mollities ossium.
  As already remarked, it attains an enormous size, and like the  com-
posite cysts, occasionally exists in both ovaries at  the same time. ^ In
the composite as in the  alveolar cyst, one  peripheral  follicle is  subject
to preponderating  groAvth, and establishes ovarian dropsy.
  To the  above special observations we add the folloAving remarks as  '
important for the diagnosis.  Generally but one ovary is affected, though
the two are  often  attacked successively, so  that the increase of size is
much more considerable in one than in the other.
  The enlarged ovary remains within the pelvis  as long  as  it does not
exceed certain dimensions ;  it either continues freely movable betAveen
the uterus and  its  lateral appendages and the rectum, or  becomes fixed,
and, as it Avere, wedged  in by the formation of false  membrane.  If it
increases still further, and  is adherent to the pelvis, it  grows into the
abdominal cavity; othenvise it leaves its previous position, and rises into
the abdomen, where it continues movable, until, in consequence  of peri-
toneal inflammation, it has formed adhesions with  adjoining viscera, or
becomes fixed by entirely filling out the cavity.  In the  course  of this
change of position, it drags the  uterus after  it by means of its ligament,
so that this organ,  together Avith the vagina, is not only  elongated, but
obtains a slanting form, Avhich is recognizable by the oblique and elevated
position of the  os tincae.   (Page 214 and 215.)
   If  both ovaries  are  involved  in  the  disease, inasmuch as they are
generally affected successively, and  one is less enlarged than the other,
the smaller one remains in the pelvis, and  its retention is proportionate
to the obstacles offered  to its ascent by its fellow.   It is  wedged in be-
tAveen the uterus and the rectum, even if there are no  adhesions.   If
we find the above-mentioned irregularity in the uterus and the vagina, and
at the same time  discover an immovable tumor in the  pelvis, which
weighs upon  the posterior walls of the vagina, and pushes  it, together
Avith the uterus, forwards, it may be assumed, if there are no contraindi-
cations, that both ovaries are diseased.
   The  cysts very frequently become the  seat of  inflammation.  This
either attacks at different periods the peritoneum, investing the diseased
ovary, and causes its adhesions and  fixation  in the abdominal cavity, or   *
the fibro-serous parietes of the cysts themselves inflame,  and the result-
ing products are deposited upon their internal surface or in their cavity.
Thus Ave find not only all the exudations with their metamorphoses, that
occur on the normal serous membranes, at this place, but also all  the fur-
ther effects of this variety of inflammation.   Our observations, hoAvever,
lead us to except the tubercular metamorphosis of the inflammatory pro-
duct ; we, at least, have never met with it, in spite  of very extensive and
various opportunities.
   As  the dropsical ovary enlarges, it occupies more and more of the
abdominal cavity; it distends the belly to an enormous extent, pushes
the intestine into  the inguinal regions, forces the  epigastric viscera, to- 
THE  OVARIES.
251
gether with the diaphragm, into the thorax, and causes universal emacia-
tion, proportionate to the increase of the tumor.  The adventitious growth
enters into combination with fibroid and carcinomatous products,  and
especially with medullary cancer, in the manner which we shall have oc-
casion to explain further on.  It is the less frequently complicated with
tubercle, the more it approaches the character of areolar cancer, and the
more it compresses the thorax by its increase of size.
   There are a  few cases on record in which the dropsical ovary is said to
have discharged its  contents into the Fallopian tube, and thus into the
uterus, and externally.
   8. The simple cyst,  or the cyst with secondary endogenous formations,
also occurs in the shape of cystosarcoma of the ovary; this, hoAvever, is
much rarer than any of the above-mentioned three varieties, and scarcely
ever attains the extreme size to which these are developed.
   e. Finally, we observe  that cysts with  anomalous contents, viz. en-
cysted fatty tumors, occur noAvhere so frequently as in the ovary ; either,
and most commonly, as a simple  cyst, or as the composite cyst, in Avhich
one of the  cysts of the  secondary formation is distinguished from the rest
by its adipose contents, or, though rarely, in the shape of a compound adi-
pose cyst.   We often find the fat associated with a formation of hair, fre-
quently, too, of teeth, and sometimes Avith the formation of bone. Like the
serous cysts, the adipose cysts are undoubtedly often formed from a Graa-
fian vesicle ; they occur most frequently in the prime of life, rarely at the
period of puberty, and still less frequently in childhood.   We have, how-
ever, one case  of adipose  cyst of the ovary in the museum of Vienna,
belonging to a child of six  years.   They grow very  slowly, and  rarely
exceed the size of a child's head. There generally is but one adipose cyst
in one of the ovaries;  the two are rarely affected at the same time.
   The  inflammation to which this  variety is equally subject with the
other cysts, gives rise to a dilatation of the cyst, as well as to an essential
alteration in its contents by means of the exudation.  It occasionally ter-
minates in suppuration, and  discharge of the contents externally at the
navel, in the hypogastric, or inguinal regions ; the  contents consist chiefly
of pus mixed up with hairs.  Under certain circumstances, which will be
explained in the sequel, the partially liquefied contents of an  adipose
cyst assume a peculiar form.  In a female, 46 years  of age, Avho died of
internal hernia, the right  ovary was found converted into an  ellipsoid
fibrous sac of the size  of a man's head, and nine inches in its long diame-
ter ; it had mounted above the pelvis, and lay obliquely in the left iliac
fossa.   Its inferior apex Avas attached to the ovarian ligament; the other,
Avhich was  directed upwards and  outwards, was attached  to the anterior
surface of the middle portion of the jejunum, by means of a cellular band
of an inch  in breadth.   The sac had been twice turned upon its axis ;  it
contained a brown, fatty, gelatinous fluid, in which, besides a ball of the
size of a walnut, composed  of hairs that were matted together, there
floated  seventy-two  bodies  of  the size  of a filbert, and a  much  larger
number of smaller bodies of the size of a  pea, consisting of a greasy fat.
They were of a yellowish color, and from mutual pressure had a polyhe-
dral surface, and  presented  concentric layers.   The cyst was not only
surrounded by coils of the small intestine, but two portions of intestine 
252
ABNORMITIES  OF
also passed underneath it.   It may therefore be said to have represented
a capsule, which both  from its form and attachment, and  from the cir-
cumstances of its having  been found rotated upon its axis, resembled a
dredging-box (granulirbiichse), the  rotations of Avhich had converted the
contained fat into the  globular bodies above described.
  b. Anomalous production of fibrous and osseous tissue.
  a. Fibrous tissue is  formed—
  In the shape of fibroid exudation on the internal surface of the simple
cysts, but more especially on that of the composite and areolar cysts.
  As a subperitoneal (subserous) new groAvth (so-called cartilaginescence)
in the cystic parietes.
  As a fibroid tumor ;  this rarely attains a larger size than that of a hemp
seed or pea.   We must except those cases in which the tumor has formed
in the parietes of a compound cyst.
  As a dirty white or yellow,  plicated, curled, soft concretion, within
which, not unfrequently, a cavity may be traced.  These concretions ap-
pear to be Graafian follicles Avhich, after having undergone inflammatory
thickening, shrivel up and become obliteVated;  after puerperal processes
Ave find them occasionally in the  shape of soft,  collapsed, friable sacculi,
whilst under other circumstances they appear as solid, dense, coriaceous
cysts.
  As a cicatrix, presenting a rounded, nodulated Avheal, with  a yellow,
rusty, or black nucleus, resulting from follicular apoplexy of the ovary.
  /9. A formation of bone occurs—
  In the shape of so-called ossification (earthy concretion) in the majority
of the just-mentioned fibroid groAvths, and more particularly in the fibroid
exudation, and in the subserous fibroid formations of the  dropsical ovary.
  As genuine bone, in various forms that offer but  a weak analogy to one
another, and in the adipose cysts.
  c. Tubercle.—The occurrence of  tubercle in the  ovaries is at least
doubtful;  so  far as our OAvn investigations  and  observations  go, Ave must
deny it altogether.
  d. Carcinoma.—Cancer, on the other hand, if Ave collect all that comes
under this denomination, is not unusual.
  a. The  most frequent form is areolar cancer in  the  above-described
shape of areolar hydrops ovarii; the conversion of the peripheral follicles
of the ovary into large sacs, is  a peculiarity which but rarely presents
itself in other tissues.  We have already alluded to all the  important
points connected with  this subject.
  ,5. Medullary carcinoma is less frequent than the former.   There are
tAvo A'arieties.  The first  occurs  in  the shape  of rounded  adventitious
growths, varying in size  from a goose's egg, to a child's head, and in-
vested with a fibrous sheath; it sometimes perforates the latter,  and groAvs
freely into the peritoneal  cavity.  In  the interior we occasionally find
large masses of cellular tissue traversing the substance of the tumors in
the shape of septa,  and inducing considerable density  of the mass;  at
other times the entire ovary appears infiltrated  with  soft  encephaloid
matter, so as to present fluctuation.   The carcinomatous matter is either
genuine Avhite cancer, or it contains pigment-cells, which vary in arrange-
ment and  number; in the latter case it  is brown or black, spotted  or 
TnE  MAMMARY GLANDS.                 253
striated, or black throughout (cancer melanodes).  It occasionally is com-
bined with the formation of cysts, the latter being either developed on
the free surface of the peritoneal sheath of the ovary, or underneath the
latter, and in the peripheral layers of the stroma.
  This variety occurs in complication Avith peritoneal cancer, with uterine,
mammary, and A'entricular cancer, with cancer of the lymphatic o-lands
and the rectum, and universal  cancerous  deposit.  Close adhesions are
sometimes formed  betAveen it and the adjoining cancerous rectum, so that
there is often considerable difficulty in ascertaining which of the tAvo
organs is the primary seat of disease. Both ovaries are very often affected.
  In  the  second  variety, racemose,  fimbriated, fibrous, vascular excre-
scences, containing  a  milky or creamy juice, or an encephaloid pulpy
mass, form on the internal surface of the peripheral follicles of areolar
cancer,  or of one of the sacs of the compound cysts, or even upon the
internal surface of a small primary cyst.  They are often very numerous
and  attain a considerable  length; they become condensed into  large
masses, and after  perforating the parietes of the  cyst, sprout through  it.
  This  form is often, though not invariably, coexistent Avith areolar
cancer of the ovary  or of  other organs.
  y. Fibrous cancer (scirrhus)  occurs very rarely in the ovary.

          SECT.  V.—ABNORMITIES OF THE  MAMMARY GLANDS.

  § 1.  Arrest and Excess of Formation.—Froriep has lately recorded
an extremely rare case of absence of one of  the mammary glands in a
female; the muscles and bones of the corresponding or right side of the
thorax  Avere imperfectly developed.  The mammae are found imperfectly
developed in those cases in which the sexual  apparatus generally is de-
fective, and Avhere certain parts of the latter, or the entire individual,
present an hermaphroditic appearance, approaching the male type.  An
excess of development occurs in various degrees  and forms : in the first
instance Ave find an  increase in the number of nipples, one gland being
provided  Avith two or  three; .or  there may be supernumerary glands, a
third one  being placed under one of the normal or between the two breasts.
Sometimes the accessory  gland is situated  externally in the armpit,  or
there may even be a third, fourth, and fifth, Avhich are arranged symme-
trically under the normal  breasts, and are always smaller than the latter.
We include under this head  also, the precocious  development of the
mammae in premature puberty, as well as  the development occasionally
found in the mammae  of  man approaching  the female  character, either
with or without an arrest of development in the genital organs.  An ex-
cess of  development is occasionally simulated by the gland being sepa-
rated into several lobes.

  § 2.  Anomalies of Size.—In  addition to the anomalies spoken of  at
the end of the preceding  section, we  here  allude to the increase in the
size of  one or, more commonly, of both breasts, developed spontaneously
or after sexual excitement in either sex, or in the female sex after par-
turition.  It consists in a  hypertrophy of the gland and of the surround-
in <r fat.  The enlargement may attain a most extravagant extent, so as 
254
ABNORMITIES  OF
even to overwhelm the powers of growth in other parts.^  Hypertrophy
of the gland is very often introduced by violent congestion, and accom-
panied by a secretion of milk.
   A diminution or  atrophy of the gland, as a morbid process, occurs in
the shape of premature involution, both in consequence of the effects of
over-nursing, as well as from the sexual functions being  completely in
abeyance.

   § 3.  Biseases of Tissue.
   1. Inflammation.—Inflammation of the mammary gland occurs very
rarely, except in consequence of various causes that operate during the
puerperal state, and during suckling.
   The gland is never attacked throughout, but the inflammation appears
at distinct spots of various dimensions,  or is, as it Avere, reduced to them
in the course of its progress ;  and whilst it is here developed with greater
intensity, becomes moderated and recedes at all other points. Its symp-
toms are, besides tumefaction of the  gland  at the seat of disease, conges-
tion and reddening, by which the natural appearance of the gland is ob-
literated, and  made to resemble flesh: there is also hardness and resis-
tance,  with  increased density of the  parenchyma,  which has  lost its
toughness, and has  become friable and  lacerable.   The  gland  is infil-
trated with a coagulable product, containing more or less reddish serum.
Cure may ensue by resolution or absorption of the product, or the pro-
cess may pass into more or less considerable induration, which at  times
is very obstinate, or, again, it may terminate in suppuration or abscess
of the gland.
   Inflammation of the  mammary gland  not unfrequently coexists with
one of the above-described puerperal diseases, though there is no essen-
tial relation between the two  affections.  The resulting abscess is  to be
carefully distinguished from the deposition of pus, consequent upon its
absorption in metrophlebitis.
   2. Cirrhosis of the mammary gland.—There is a certain condition of
the breast which, from all that we know of it, seems comparable to  cir-
rhosis of the liver  and the  lungs (bronchial dilatation).  We have been
unable to ascertain  whether any particular disease gives  rise to it,  but
there is every  reason to suppose that it is the  result of protracted suck-
ling.
   3. Adventitious growths.—A great  variety of adventitious groAvths
occur in  the mammary gland; some  of these are unusual, whilst others
are very frequent.   They affect mainly the female breast, and  only ex-
ceptionally, and from very  remarkable  influences, the male breast.
   a. Cysts.—The simple cyst, with serous, albuminous, or colloid con-
tents, as well as the adipose cyst, Avith  or without the formation of hair,
is very uncommon ;  the compound cyst is equally rare.  Not so, hoAvever,
   b.  Sarcoma.—This is of  common occurrence, and it often assumes the
shape of encysted sarcoma, the cysts being either simple, or presenting
the endogenous development of secondary cysts ; this form is the hydatid
tumor or hydatid mammary carcinoma  of English writers.   All the  sar-
comatous groAvths are  liable to attain  a  considerable size, they are  fre-
quently recognized as such, and may be extirpated successfully. 
THE  OVUM.
255
   c. Fibroid  tumors and enchondroma.—These are not frequent; we
have  observed the former a  few times, but only of small dimensions.
Johann Miiller has seen one instance of the latter.
   d.  Tubercle.—According  to our own  observations,  tubercle  never
occurs in the mammary gland.
   e. Cancer.—Cancer, on the other hand, which is found to occur in
almost all its varieties, is the more frequent; mammary and uterine cancer
alone suffice to give to the female sex a vast preponderance over the male
sex, as to the  frequency of cancerous affections.   The  different  forms
may occur by themselves, or in combination Avith one another; medullary
carcinoma is particularly liable to form upon a scirrhous matrix.
   a. True scirrhus, or fibrous cancer, and the following variety, are the
most common.   Scirrhus presents the Avell-knoAvn characters  of a carti-
tilaginoid, immovable, nodulated, branched tumor, which draws  in the
integument, and more particularly the nipple, with its areola, and is im-
bedded in fat.   Its internal structure presents a lobulated appearance,
and consists of a Avhitish fibrous stroma, and of a gray transparent crys-
talline substance, which  is deposited in the interstices of the former.  It
is often traversed by  lacteal  ducts which contain a  corrugated, whitish,
or yelloAv cheesy matter.  The ulcer that it  gives rise to is cup-shaped,
and presents a hard elevated  margin and  a sanious discharge ; extends
in all directions, but  especially backwards, so as to  involve the pectoral
and intercostal  muscles, the  periosteum of their ribs and their  bony
structure, and at  last to fix  itself immovably in the thoracic parietes.
The margin as well as the base of the ulcer degenerate into a red,  vascu-
lar, bleeding fungus,  which is distended by a whitish encephaloid  juice ;
the immediate consequence is a development of lardaceo-medullary tumors
in the most  various tissues, either in the vicinity or at a distance.   This
constitutes—
   j3. Medullary carcinoma, which however occurs not only in combination
with fibrous carcinoma, but also in a primary form ; in the latter  case it
is equally distinguished by its rapid growth, its large dimensions,  by the
much more speedy  degeneration into  universal cancerous cachexia, and
by the sponginess of the ulcer.
   y. Cancer hyalinus is  much less  frequent than either of the former
varieties ; it occasionally attains a considerable size, and has, in addition
to other peculiarities, a remarkably lobulated structure.
   Cancer of the mammary gland is generally developed after the thirty-
fifth, though it is sometimes met  with before the thirtieth year.   It fre-
quently exists by itself, but  is more commonly combined with cancer of
the adjoining axillary  glands, with  mediastinal, pleuritic,  pulmonic,
uterine, hepatic, and  cerebral cancer, with universal cancerous cachexia,
and with mollities ossium.

               SECT.  VI.—ABNORMITIES  OF THE OVUM.

   We shall first discuss  the  anomalies presented in the attachments of
the ovum, i. e. its attachment and development at a point external  to the
uterine cavity, extra-uterine pregnancy and the degeneration of the  ovum.
We shall then examine the  abnormities occurring in the separate parts 
256
ABNORMITIES OF
of the ovum, the membranes, the placenta, the funiculus umbilicalis, and
the foetus.

  § 1. Extra-uterine Pregnancy.—Extra-uterine pregnancy may take
place at difierent points;  in the order of frequency these  points are, the
Fallopian tube, the parietes of the uterus, the ovary, and the vagina.  We
proceed to state the more  important matters connected Avith each of these
occurrences.
  1. Pregnancy in the Fallopian tube (graviditas tubaria) is  the most fre-
quent of all; the ovum attaches itself either near the fimbriated extremity,
or more towards the uterus; this part of the tube  becomes dilated into
an oval sac,  with  eccentric development.    This  variety of pregnancy
generally proves fatal in the  third or fourth month by hemorrhage into
the peritoneal caArity, from rupture of the sac either with or Avithout an
escape of the foetus.   We haAre hoAvever observed this occurrence in one
case at the sixth Aveek, and in another a fortnight after conception.  On
the other  hand, an old preparation existing in the Viennese  Museum,
appears to prove that pregnancy may continue to  the sixth or seventh
month.  Of six cases of tubal pregnancy preserved in the same collection,
five are on the right side.
  2. Pregnancy in the parietes of the uterus.—This kind of pregnancy,
which has also received the name of interstitial pregnancy, and about the
seat of which  various opinions have been promulgated, is probably nothing
more than a pregnancy of  the Fallopian tube, i. e. a pregnancy occurring
in that portion of the tube which traverses the uterine tissue.  It is, con-
sequently, in a close relation with  the uterus, and  necessarily involves
the uterine parenchyma in such  a manner that  the cavity which contains
the foetus with its membranes, appears to have been developed within the
tissue of the uterus.   It will consequently be most appropriate to  consi-
der it as  tubo-uterine pregnancy.   The pregnant sac consists of uterine
tissue, its walls are of considerable thickness, and are in direct connection
with the uterus ; the sac is more or  less  distinctly seated at the side of
the fundus uteri, and uterine fibres are traceable into it.
  This pregnancy generally proves rapidly fatal by rupture ; however, it
is evident, both from our  own observations  and  those of other morbid
anatomists, that it may terminate  in a  different  manner.   At various
periods of the normal progress of pregnancy, the sac, probably in conse-
quence of the traction exerted upon it, becomes the seat  of chronic  in-
flammation, Avhich passes  into suppuration and gangrene ; after causing
the death of the foetus, this either  proves fatal by itself or  by inducing
peritonitis.  The sac may suppurate chiefly in one direction,  and thus
involve the adjoining viscera ; so that, after their destruction, it may dis-
charge its contents externally  or into the cavities of neighboring organs ;
this is  generally effected  slowly and piecemeal.   In other cases, preg-
nancy not only attains, but even extends  beyond the  full period.  The
parietes of the sac in this  case are of considerable substance and  thick-
ness ; the sac itself is capacious, and contains a mature or even an over-
ripe  hypertrophied foetus.   In one case of this description the pregnancy
lasted sixteen months, and the over-ripe foetus,  Avhich had died some time
preA-iously, Avas  extracted by opening the abdominal cavity and the sac. 
THE  OVUM.
257
   3. Peritoneal  pregnancy, graviditis peritonealis,  occurs within  the
cavity of the peritoneum ; the foetus with its membranes is surrounded by
an  organic  exudation  attached to the peritoneum, and the placenta is
found connected with the most different parts of the parietal and visceral
laminae of the peritoneum.   This form of pregnancy generally terminates
fatally at various periods by peritoneal inflammation ; sometimes the peri-
tonitis ends in suppuration, Avhich may cause the  effete foetus, together
with the formative organs, to be discharged by various passages.
  4. Ovarian pregnancy is the most unfrequent form of the extra-uterine
pregnancy ; it either terminates in laceration,  which is at once fatal, or
in inflammation and suppuration of the  sac, which in their turn  prove
fatal, or cause a diminution of the foetus.
  5. Vaginal pregnancy is not only the rarest of all, but altogether pro-
blematical.
  Although we have given an anatomical account of the  chief termina-
tions occurring in extra-uterine pregnancy, we will  add  a  comparative
analysis, and also subjoin one that we have not yet mentioned.
   Interstitial, ovarian, and tubal pregnancy terminate by  laceration; the
last two at an early period,  the first much  later, and even after the usual
duration of pregnancy.
   All the varieties of  extra-uterine pregnancy may terminate in inflam-
mation  with consequent  suppuration, owing to the decomposition of the
defunct foetus, and the putrescence of its involucra.   Inflammation may,
in advanced interstitial pregnancy, doubtless arise in the  sac  primarily,
from the traction exerted upon its tissue and upon the peritoneal invest-
ment, and thus induce the death of the foetus.   If the suppurative pro-
cess attacks the organs adjoining and adherent to the sac, the latter may
discharge itself externally through the  abdominal parietes or into the
cavity of an adjoining organ; the foetus may thus be eliminated  entire
or  piecemeal, in  a state of maceration, saponification, or putrefaction.
This has been observed repeatedly; single bones belonging to the  foetus
having been seen to pass through the navel, at different parts of the hy-
pogastric region, and  still  more  frequently by the anus or  the urinary
passages.  It is stated that, after this  has taken place, a cure may follow;
but death from exhaustion  is a  more common consequence.   The  dis-
charge  may occur long  after the usual period of pregnancy has  termi-
nated.
   Besides the above-mentioned  modes of  termination there is another,
which must  be viewed  as the most favorable one ;  in this  case the foetus
dies before or after  it  has attained maturity, and, after the  surrounding
fluids have  been removed by absorption, becomes mummefied and indu-
rated ; or if the soft tissues have already undergone a certain degree of
decomposition, it may become incrusted by a greasy, chalky substance
(lithopaedion), and in  this shape be borne for a long time in the con-
tracted sac, without much inconvenience.   This termination occurs chiefly
in peritoneal pregnancy, it has however also been observed in pregnancy
in the Fallopian tube.
  In all extra-uterine pregnancies we  commonly  observe  the forma-
tion of  a deciduous membrane on the inner  surface of the  uterus;  and
the latter undergoes, up to a certain period, the  same changes that  it
  VOL. II.                         17 
258
ABNORMITIES  OF
 would present if it contained  the foetus.  It scarcely  ever  exceeds the
 dimensions Avhich it exhibits about the first and second month of normal
 pregnancy.  This development of the uterus is undoubtedly more  consi-
 derable in interstitial  and tubal pregnancy, than in the other varieties
 of extra-uterine pregnancy, and may be considered as analogous  to the
 development of the unimpregnated half of the uterus bicornis or bilocu-
 laris.

   § 2. Begeneration of the Ovum.—We here  but allude to those cases of
 degeneration of the ovum which are  called moles,  and which  are dis-
 tinguished according to their external appearance, structure, and density
 as carneous, vesicular moles, &c.  We exclude all abnormities in the for-
 mation of the foetus, and remark that moles generally contain no foetus,
 as the degeneration of the membranes and the placenta mostly occurs at
 a very early period of pregnancy, in consequence of which  the  embryo
 dies and disappears, the cavity of the amnios remaining persistent or be-
 coming obliterated.  The diseases in which the moles of which we  speak
 originate, will be adverted to  in the following pages, and Ave shall  take
 care to point out the connection.

  § 3. Abnormities of the separate parts of the Ovum.

  1. Abnormities of the Membranes and of the Liquor Amnii.—Themem-
 branes of the ovum may undoubtedly become the seat of hemorrhage and
 inflammation at a very early period of pregnancy; these affections are
 probably the cause  of the formation of moles, but they may also give rise
to abortion.  The dirty white and ash-colored spots occurring  in various
 sizes upon the amnion, and accompanied by thickening of the membranes,
 and the opacity sometimes affecting the greater part of the amnion, evi-
 dence previous inflammation.  But under this head we must more parti-
 cularly instance the deposits of a grayish-red,  whitish,  or yellowish  sub-
 stance, occurring on the chorion and the decidua, in the shape of patches.
 The membranes here present a thickening without distinct edges, or flat-
 tened rounded nodules ; the tissues being either softened  and friable, or
 indurated and dense.   Occasionally the membranes, in consequence of a
 cretification of the deposit, are incrusted, or  contain a chalky grit.
  The albuminoid layer which represents the so-called tunica media, is
 not unfrequently morbidly  increased  in  quantity;  sometimes  a  thin,
 braAvny, or Avatery accumulation is substituted  for it, and to the latter the
 discharge of the so-called spurious liquor amnii in the second half of preg-
 nancy, is  probably due  (hydrallantois).   In other cases its amount  is
 very small, or it presents greater consistency, and may even be tough and
 membranous.
  The villi of the chorion degenerate at an early period of  pregnancy,
 into pedunculated vesicles or cysts, which are placed at their extremities ;
 a degeneration  which is also seen in the placenta ; when occurring  in an
 extensive and advanced degree they represent what has been termed the
 vesicular or hydatid mole.
  Occasionally  we discover more or  less extensive adhesions between the
 embryo and the amnion, which is a circumstance  of some  importance on
 account of  the impediment it  offers to the proper development of the
 foetus. 
THE  PLACENTA.
259
   The liquor amnii is sometimes so much reduced in quantity, that the
 foetus is closely invested by the amnion, at others it is excessive (hydram-
 nios); it is also found more or less opaque, discolored, and fetid.

   2. Abnormities of the Placenta.—«. The placenta offers considerable
 variations as  to  size, without being  morbidly affected.   We have  here
 only to mention that extreme development of the intervascular substance
 of the decidua which compresses the vessels; as well as the occurrence
 of atrophy with  relaxation, a  contraction accompanied  by coriaceous
 toughness, the causes and original seat of which doubtless vary, but with
 the  exception of inflammation are unknown.
   (3. The placenta presents no remarkable pathological  changes in point
 of form, with the exception of its  division into  a few large or numerous
 smaller lobules.   The various shapes presented by the placenta  offer no
 interest in reference to pathology.
   y. The placenta presents numerous deviations in regard to position ;
 its position at the inferior  segment of the uterus deserves particular men-
 tion, as its eccentric or  concentric development  at the  os uteri  induces
 considerable perils towards the  end of pregnancy, by giving rise to fre-
 quent and lasting hemorrhage.
   8. Allied to this hemorrhage are the floodings which, though  the pla-
 centa  occupies its normal position, are brought on by concussion or con-
 tusion of the  pregnant womb, inducing a  forcible separation of  the pla-
 centa  from the uterus, or a laceration of the former, or which  are  the
 result of rupture of the uterine vessels of the placenta caused by  extreme
 congestion.  Whether  or  not  accompanied  by external bleeding, they
 represent apoplexy of the placenta, one of the  most frequent  causes of
 abortion ; the blood may be diffused through the parenchyma to a greater
 or less extent, or be extravasated  and accumulated  at  one  spot, which
 may either adjoin the uterine parietes  or  be situated deeply within the
 placental tissue.   The placenta is undoubtedly sometimes affected  with
 plethora,  congestion, and diminution  in the rapidity of the circulation, a
 condition Avhich is important on account  of the impeded vivification of
 the foetal blood.   It is then of a darker color, externally and internally
 of a dark violet or livid hue, the vessels are overcharged, the entire organ
 appears enlarged  and heavier, and feels harder  and denser.
   e. Among the textural diseases inflammation  is the most frequent; it
 generally occurs  in the lobular' form, as it  attacks small  sections or
 lobules, and rarely larger portions  of the  placenta.   Still a considerable
 portion may be simultaneously or successively attacked even in the  first
 instance, inasmuch as the  products of the process are found  scattered
 over numerous spots.  It recurs at different or new points to the end of
 pregnancy ; an opportunity is thus presented of observing it,  if not in its
 first stage, at least shortly after the  formation of  the  product, and of
 tracing the metamorphoses of the latter.
   Inflammation of the placenta  generally gives rise to a  plastic fibrinous
 deposit, which is reddened by the coloring matter of  the blood which it
 contains, and by Avhich the diseased portion is rendered denser and more
lacerable.  This may be termed hepatization of the placenta; it may be
recognized by the increased resistance and nodulated tumefaction pre- 
260
ABNORMITIES  OF
sented to the touch.   In the course of time the deposit assumes a pale
red, grayish or yellowish-red, or even yellowish-white tinge; at the same
time it becomes firmer, and together Avith the included obliterated tissue,
contracts  and  shrivels.  The inflammation has  thus  terminated as  it
usually does, in induration  and obliteration of the placental tissue, which
is converted into an ashy, tough, leathery callus, resembling elastic tissue.
  It appears an established fact that an adhesion may form between the
placenta and the uterus in  consequence of a process of  this  kind;  the
extent as well as the intimacy of the union naturally varies.
  In rare cases the inflammation may give rise  to a purulent product,
causing suppuration of the  placenta in the shape of circumscribed globu-
lar  abscesses, or of diffused infiltration and fusion of the  placental tissue
—phthisis placentae.
  The question as to the seat of the inflammatory process, or rather as
to which of the vascular systems is affected, has not as yet been answered;
doubtless  either of the two may be involved, and it is to  be presumed
that in both cases the results will be the same, on account of the intimate
connection existing between them.
  Inflammation and consequent obliteration of the placenta are the more
likely to induce imperfect nutrition, and  consequent tabes of  the foetus,
the more they are diffused  and the greater the number of placental  sec-
tions attacked at the same  time.
  The foetal portion of the  placenta, as we have already mentioned when
speaking of the villi of the chorion, is not unfrequently attacked by a
degeneration in the shape of round or oval, fusiform, pedunculated,  serous
vesicles or hydatids,  which diminish, and even  entirely obliterate the
cavity of the amnion.   This is a vesicular or hydatid  mole, Laennec's
acephalocystis racemosa.
  Foreign observers have given instances of  osseous deposits  in, or ossi-
fication of the placenta; they are gibbous, nodulated, or cordate forma-
tions, which are probably developed in the placental tissue after  it  has
been obliterated by inflammation, or in the fibrinous coagula caused by
hemorrhages.
  Tubercle does not occur  in the placenta; one must be careful not to
confound the product of inflammation, which sometimes has a cheesy, fria-
ble, and chalky appearance, or a fibrinous coagulum caused  by hemor-
rhage, which  is undergoing a  similar metamorphosis,  with  placental
tubercle.
  The observations recorded of scirrhus,  or scirrhous degeneration of the
placenta, may justly be considered as erroneous; the cases described as
such, are  obliterations of  the placental tissue after inflammation, indu-
rated inflammatory products, or old, shrivelled, decolorized extravasations
of  blood, &c.   Adhesions  similar  to those which  we mentioned when
speaking of the membranes, are found to occur between the placenta and
the foetus.

  3. Abnormities of the Umbilical Cord.—The instances of absence  of
the funiculus umbilicalis, recorded by ancient writers, must evidently, as
Meckel has pointed out, be considered as cases of extreme  shortness  of
the cord.   The subject is of considerable importance on account of its 
THE  FCETUS.
261
influence upon arrest of development, particularly of the inferior half of
the foetus.
   The cord varies considerably in length.  Davis  has seen one of two,
Montault of four, Meissner and myself of five inches only; whilst on the
other hand, Baudelocque has noticed  one of forty-six, and Heriter one
of fifty-seven inches.   In the Viennese Museum there is a cord attached
to a large  placenta, which measures fifty-four inches ;  and if we allow
five or six inches for the distance at which it was probably severed  from
the navel, the whole cord must have been from fifty-nine  to sixty inches
in length.
   The chief deviations as to the insertion of the cord  are the marginal
attachment, and  the insertion external to the placenta into the mem-
branes.  Occasionally we  notice a premature separation  of  the vessels,
and of the  two arteries; one not unfrequently is absent, and  the other is
then commonly a direct continuation of the abdominal aorta.
   The true knots of the umbilical cord that  occur in rare cases, are of
importance, as they may occasion obstacles to, or a cessation of, the cir-
culation, in consequence of the traction exerted upon them during par-
turition.
   Irregularities in  the position of the umbilical cord very frequently pre-
sent themselves in the shape of circumvolutions round  different parts of
the foetus ; if traction is exerted  upon them, the  circulation  may be im-
peded in the cord, as well as in the part of the foetus which  they surround.
   Rupture of the umbilical cord, or of its component vessels, and espe-
cially of the vein, are of very rare occurrence. They result from extreme
traction, when the cord is either too short or twisted.
   Adhesions have  been  noticed in rare cases between  the  funiculus
umbilicalis, and the foetus and the membranes.
   The gelatinous matter of  the cord  is either excessive, and the  latter
then appears much enlarged;  or it is diminished  in quantity, in which
case the cord is thin, flabby, and corrugated.
   The umbilical vein presents  varicose dilatations and  contractions, the
latter particularly in the vicinity of the navel.  The sheath  of the cord
occasionally contains serous cysts.

   4. Abnormities of the Foetus.—We  pass over those deviations of con-
genital  development which we  have already  discussed, and  devote this
section  to  the consideration of the remaining anomalies, although  we
have already cursorily touched upon most of them.
   We not  unfrequently meet with  a  hypertrophy of the foetus, or  of
individual organs and  sections  of the  foetal  body.   Children are some-
times born, either at the proper period or later, of excessive dimensions,
over-nourished and endowed with  all the characters of over-ripeness.
Among the partial hypertrophies we have to specify those of the brain,
of the thyroid and  thymus glands, the hypertrophy of certain parts of
the skeleton, as the premature development of the cranium, the excess in
the digital  phalanges of the hands or feet, the so-called  hypertrophies of
the liver and the spleen.
   The entire  foetus may be atrophic, in  consequence of the cachectic
state of the mother; but those  cases are of greater  importance which re-
sult from disease of the membranes, the placenta,  and  the cord; and if 
262
ABNORMITIES  OF
occurring at the earliest period of embryonic life, may cause the embryo
to disappear  entirely, or  so  far  as  to leave but mere traces.  Partial
atrophy, as a result of disease in the nervous centres, occasionally affects
the extremities; in rare cases, it may be the consequence of pressure ex-
erted by the uterus on the funiculus umbilicalis.
  The  most  various  curvatures and  malpositions of the bones  (pes
equinus), curvatures and dislocations of the joints, maybe brought on by
contraction of the  uterine  cavity, external pressure, convulsions,  and
tonic spasms of the foetus.  Convulsions or traumatic injuries may induce
fractures of the bones, and even rupture of the abdominal viscera,  and
especially of the liver and the intestines.
  To these lesions of continuity we have to add the spontaneous ampu-
tations  of extremities (Simpson, Montgomery),  occurring at an early
stage of embryonic life ; they have not as yet been sufficiently accounted
for, and are to be carefully distinguished from cases of arrest of develop-
ment.
  The foetus may be affected by general plethora, as well as  by conges-
tion of  separate organs, which  ultimately degenerates into hemorrhage
and apoplexy.   The brain and  spinal marrow and their membranes, the
thyroid gland, the  liver,  the kidneys, and  the suprarenal capsules are
particularly liable to be attacked.
  A most important morbid process and one of very frequent occurrence,
the peculiarities of Avhich  in the foetus  are almost unknown, is inflamma-
tion.   Its terminations and consequences are of great value in regard to
the doctrine of deviations  of formations, for a reconstruction of which we
are particularly indebted to Simpson, whose views on  the subject are of
peculiar interest.  Inflammation  attacks almost all the organs, including
those peculiar to foetal life, the thymus, and the  suprarenal capsules.
Its terminations and consequences the  more resemble  those which it pre-
sents in the infant  and adult, the more mature the foetus, the more de-
veloped the tissues attacked, are.  It gives rise to plastic products with
adhesions between  adjoining organs, accompanied by the most various
new formations; it induces suppuration and suppurative destruction,
though very rarely  induration.   On the other hand, it  causes in  very
delicate embryos, and in  particular tissues of peculiar delicacy, a very
rapid dissolution, or liquefaction, either of a benignant or a malignant
character.
   Dropsy of the different cavities and anasarca, have been noticed in the
foetus;  among the former, hydrocephalus and hydrorrhachis  are both in
themselves, and on account of the consequent arrest of development and
the malformation of the cranium  and of other parts, of chief importance.
Cutaneous dropsy sometimes attacks the foetus in a very eminent degree,
and is  generally combined  with dropsical  accumulations in the large
cavities.  It has been particularly and repeatedly observed  in the chil-
dren born of women  Avho had themselves  suffered from dropsy during
pregnancy (West); it also occurs under other circumstances, and in these
cases probably originates  in obstacles to the circulation through the um-
bilical vessels and the foetal portion of the  placenta.
   Even adventitious groAvths occur,  though rarely,  in  the foetus • we oc-
casionally discover cysts,  particularly the simple cyst,  lipomatou's, sarco-
matous, and even cancerous products.  Although many of the cases  that 
THE  FCETUS.
263
have been considered as cancerous, rest upon a misapprehension, the oc-
currence  of carcinoma is undoubted and of peculiar interest.   Fcetal
cancer is  allied  to  the  cancer, and especially to the medullary variety,
occurring during infancy ; we  communicate the folloAving  case that we
have ourselves observed, as one of peculiar interest.
   A female infant, of 16J inches  in length, and 27 days old, presented
in the region of the pudenda, anus, and sacrum, a tumor tensely invested
by the cutaneous covering.  It was of the size of a goose's egg, and had,
towards the  sacral and loAver lumbar vertebrae,  a  conoid process  of the
size  of a hazel-nut.  On its left side were noticed  the  vaginal and anal
opening, which Avere pushed downwards and separated, the latter appear-
ing in the shape of an  excoriated semilunar fissure. The child was born
with this tumor.  It  lay  external to the pelvis, under  the skin and the
perineal muscles; posteriorly, fibres of the glutaeus magnus spread over
it.   It  was surrounded by a fibrous sheath, and consisted  of various
tissues ; the inferior third, and the portion that lay more  to the right,
resembled the reddish-gray cerebral substance  of  an infant's  brain,
whereas the two upper thirds  presented  a follicular  tissue with small
loculi, containing a  grayish  gelatine.   The tumor extended into the
pelvis by  the inferior aperture, in the shape of an oval serous cyst of the
size  of a walnut, the internal surface of which appeared here and there
to contain a black pigment, and presented a few ridge-like  duplicatures.
The follicular portion of the morbid product also forced its  way through
the sacral fissure into the medullary canal, and then presented a process
closely resembling the external conical process, except that it was smaller.
   This  adventitious product  is  nothing  more  than  a combination of
areolar  and medullary  cancer,  the circumference of which  is converted
into  a cyst.
   Tubercle occurs but in very rare cases in the foetus ; we ourselves have
never observed it.
   The foetal fluids are undoubtedly liable to numerous acute and chronic
morbid affections, as is  evidenced by the occurrence of various exanthe-
matic and impetiginous diseases, as well as cachectic disorders, such as
rickets,  syphilis, tubercle, peculiar  hypertrophies of the liver, the spleen,
the lymphatic glands.
   Variola, measles, and various cicatrices haAre been noticed on the foetal
integuments.  To this head also pertains pemphigus and various vesicular
eruptions, the vesicles of  which  contain a livid,  sero-purulent  fluid, are
converted into ulcers, and may be  traced to syphilitic causes.  We also
find ecchymoses, petechial suffusions of the skin, shallow or elevated naevi,
of a  brown or livid hue, and of different sizes.  The subcutaneous cellular
tissue is the seat of anasarca and of many of the above-mentioned tumors
and morbid  growths; shortly after birth, it is frequently attacked with
induration.                                         .
   The serous membranes are found  more frequently inflamed than  any
other tissue, or  the previous  existence of inflammation in them  is  evi-
denced by adhesions of the organs which they invest; these, undoubtedly,
give  rise to many of the anomalies in the position of these organs, which
are in part at least looked upon as the consequence of original malfor-
mation and  arrest of development.
   Peritoneal inflammation is, doubtless, the most frequent, and it is upon 
264                     ABNORMITIES  OF
this fact and upon the adhesiA'e termination of the disease, that Simpson
bases his views regarding many of the anomalies that are commonly con-
sidered  as cases of arrest of development.   Inflammation of the pleura
and pericardium are less frequent.
  Among the mucous membranes, that of the alimentary tube is the chief
seat  of  disease, as we  shall have  occasion to explain  more fully in the
sequel.
  In addition  to the above-mentioned  fractures, dislocations,  and spon-
taneous amputations, we find  the  osseous system  liable to  suppurative
inflammation (caries), hyperostosis, and  an exuberant  deposit of callus,
an arrest in the process of ossification, which is allied to rhachitism
(rhachitis congenita).
  The morbid processes  in the muscular system which we  chiefly meet
with, are contractions; they depend mainly upon diseases of the nervous
centres.
  The heart is liable to be affected, in the first instance, by  pericarditis;
in the second,  by endocarditis.  It is very remarkable, that the relation
of the latter to the  cavities of the heart is the reverse of  what occurs
after birth.  The dilatations and valvular affections observed  at the left
ventricle and its arterial orifice in the adult, as a  consequence of endo-
carditis, are here  found to attack the right ventricle  and the valves of
the pulmonary artery.
  The stenoses observed in the latter, which originate in a  morbid  me-
tamorphosis of the valves, are to be carefully distinguished from cases of
arrest of development occurring here, especially in the shape of atrophy
of the pulmonary artery, resulting from anomalies  in the structure of the
heart.
  The ductus Botalli is in rare cases liable to an aneurismatic  dilatation,
and in this respect resembles the aorta in extra-uterine life.
  The brain and the spinal cord are particularly subject to disease in the
foetus;  and  these affections are undoubtedly the cause  of many defects
and malformations of the brain and spinal cord, their membranous sheaths
and osseous cases, and of defect and malformation of other organs which
have hitherto been considered as anomalies of original  development.
  Thus we obserA'e hypertrophy of the brain, which in  rare  cases attains
such an extent as to cause  the development  of the cranium  to  appear
entirely arrested.
  Apoplexy occurs very rarely as hemorrhage within  the  substance of
the brain; but we often find both in the foetus and the new-born infant a
vascular apoplexy, and  extravasation into the tissue of the membranes
and into the cavity of the arachnoid.
  Inflammation and its  consequences, inflammatory softening and com-
plete liquefaction of the brain, are much more frequent.   These  and
hydrocephalus are doubtless the commonest cerebral diseases  of the foetus,
and  upon the  former the defects  and numerous  malformations depend
which are found in hydrocephalic foetuses.
  Hydrocephalus and hydrorrhachis are, in the foetus as at a later period,
the result of repeated exudative processes affecting the investments of
the cerebral cavities and the spinal canal.  They are  well  known often
to attain such a degree, that not only the dilated and imperfectly ossified 
THE  FCETUS.
265
cranium offers  an  obstacle to  parturition,  but  that  the brain  and
the spinal cord are  gradually destroyed by compression ; that they are
ruptured at an early stage of embryonic life, or are dislocated in various
directions, and forced out of the cranium  at later periods.
   In the respiratory apparatus of the foetus  Ave find that the pulmonary
parenchyma and the bronchi occasionally  become diseased.  The former
is said to have been found in a state of  hepatization, and even abscesses
have been seen in the lungs.  The bronchi are frequently charged with
mucus, and atelectasis  neonatorum is probably caused by a mere ca-
tarrhal affection  of the mucous membrane,  and an  obstruction of the
capillary bronchi by mucus.  (Vid. Vol. III., Acute Catarrh of Respir.
Org.)
   The thymus gland of the foetus may, according to Veron, be attacked
by inflammation and suppuration.
   In the digestive apparatus, the peritoneum, the  entire intestine,  and
its appendages may become diseased during uterine existence.
   The peritoneum is frequently the seat of inflammation of an acute or
chronic character, causing exudations, that vary in  quantity and quality.
It may be limited to one portion, or be universal.  It not only induces
thickening of the peritoneum, but  also adhesions among the abdominal
viscera, and between them and the parietes; the sooner it sets in, the
more it is likely to operate as the  cause  of  numerous  anomalies in the
abdomen, which have been  hitherto considered as  cases of arrest of de-
velopment.   (Simpson.)   The inflammation  may  originate in unknoAvn
causes, or in such a*s are anatomically demonstrable, as constriction of
the intestine, hemorrhage of the liver into the peritoneal  cavity, extra-
vasation of  the contents of  the  intestines, or of urine; the latter may
occur at a Arery early period, for it has been noticed in a foetus of four
months.   It sometimes kills the  foetus before  maturity, at others death
ensues shortly after birth.
   As regards the alimentary tube, both hyperaemia of  its  mucous mem-
brane and  anaemia, Avith waxy  paleness  and  softening, have  been fre-
quently observed.  The latter affection is of particlar importance in the
foetus.  The former not unfrequently attains such a degree as to  warrant
the application of the term apoplexy; it is generally associated with hy-
peraemia of  other abdominal viscera and  general plethora, and may be
accompanied by ecchymoses in the tissues  and extravasation of blood into
the intestinal cavity.
   Inflammation and the allied  processes are  generally limited to  the
follicular apparatus of the ventricular and intestinal mucous membrane,
which are comparatively very much developed.   The former occasionally
presents a  hemorrhagic fusion (erosion) of the follicles in a very marked
degree; the follicular apparatus  of the intestinal mucous membrane is
still  more frequently diseased.   In  the  small intestine, the  glands of
Peyer are chiefly found more or less swollen, reddened, and of a fleshy
sarcomatous appearance, or pale, i. e. yellow or grayish-red, containing
like the solitary follicles, a  variety of reddish  or grayish, more or less
dense, opaque, milky or curdled,  serous, flocculent fluids.  These morbid
enlargements of the intestinal follicles, caused by tumefaction and im-
bibition of the tissues, and the presence of a A'ariously modified product,
   VOL. II.                       18 
266
ABNORMITIES  OF
are here too undoubtedly (vide p. 78) closely associated with anomalies
in the vital fluids, with morbid conditions of the mesenteric glands, ab-
normal  enlargement of the thymus, or with tumefaction of the spleen,
but their real nature remains an enigma.   The  indurated  swellings of
the Peyerian glands occasionally resemble closely the typhoid infiltration
found in adults, and may  indeed result, if not from an identical, at least
from  a  very similar process.  Follicular tumefaction  also  occurs fre-
quently in the large intestine of the foetus and the new-born  infant; and,
as in  the adult, without any coexistent  affection  of the small intestine.
The  follicles  appear much  reddened, the  entire mucous membrane is
swollen, and invested with a yellowish-white secretion. ^
   In  very rare cases we meet with a  diffused croupy inflammation, and
a corresponding product in the intestinal mucous membrane.
   The processes which we have  just considered,  do  not appear to lead
to ulceration in the foetus; still there are cases  on  record  of extensive
ulcerative affections of the oesophagus and the entire alimentary tract.
   Tumors and excrescences have been observed on  the internal surface
of the intestine, as well as callosities of the interstitial cellular tissue,
especially of the stomach.
   The foetal liver is very often the seat of hyperaemia, which, on account
of the delicacy of the hepatic tissue, easily degenerates into apoplexy
with rupture.
   Various infiltrations of the hepatic parenchyma may form even during
foeta  existence, and we thus find the fatty, the waxy, the lardaceous
liver  accompanied by the characteristic enlargement, in which the left
lobe, which at that period is comparatively of large dimensions, neces-
sarily participates.
   In  the same manner, the spleen of the foetus  may suffer ; it  is  often
found in a state of acute or of chronic tumefaction, presenting in the first
case looseness, in the second, remarkable condensation, resistency, and
frangibility of texture.  Tumors of the  spleen  bear the  same import as
in the adult, and result from the  relation existing  between the spleen
and dyscrasic conditions of the blood.  They occasionally attain a con-
siderable size.
   The salivary glands, and  especially the pancreas, are very rarely af-
fected in the  foetus ; the  cancerous induration of the pancreas noticed
at page 140 must be considered as extremely remarkable.
   The urinary organs  of the foetus do  not frequently  become diseased,
but their affections occasionally attain a very considerable development.
The kidneys are subject to hyperaemia and apoplexy; the passages have
been  found  excessively dilated, to an extent  varying with the seat of
contraction or obturation ; and the bladder has even been ruptured from
the same cause.  We quote the following case, taken from a preparation
which is preserved in the  Viennese Museum, both  because it  presents
analogies to  the various observations of this character that have been
recorded, and on account  of several peculiarities which it offers :  A new-
born  male infant with a large abdominal cavity, is provided with a blad-
der of the size of a child's head, collapsed and agglutinated to the  abdo-
minal parietes by a thick  exudation.  The membranes are traversed by
varicose veins, which presented  a blue color when fresh, and the urethra 
THE  FC3TUS.
267
is narrow, though patent.  The inferior portions of the ureters are di-
lated to the size of the small intestine of an adult, the upper portions less
so, the right being  of the size of a little finger, the left one larger;  the
pelves and calices of the kidneys, which are of the size  of  walnuts, are
moderately dilated.   The  ureters are coiled up  and bent,  and their
curvatures are bound down  by a tense cellular  sheath:  both terminate
blindly at the sides of the bladder.   The right one is accompanied by an
unsymmetrical umbilical artery, which proceeds from the point of origin
of the renal arteries.   All the other abdominal viscera  are pushed up-
wards, and the entire intestine is  very narrow,  scarcely presenting  a
diameter of one line ; the abdominal integuments are oedematous, and are
superficially ulcerated, below the insertion of the umbilical cord, to an
extent of three inches by nine lines or one inch.  They are considerably
thinned,  and of an irregular thickness, presenting a cribriform perfora-
tion  at one spot, and adhering to  the anterior surface of the bladder.
The  peritoneum was invested by a  plastic exudation, and contained six
ounces of a yellow, opaque fluid.
  The cysts  of which we have spoken at page 159, also occur in the foetal
kidneys,  and may be so numerous that the latter appear converted  into
one  mass of cysts.
  We frequently have opportunities of observing spots in the foetal  kid-
neys which are variously discolored, and which  present  a  morbid indu-
ration of the tissue.  They most probably result from inflammation, and
are occasionally associated with traces  of a similar process in the adipose
sheath of the kidneys.
  The suprarenal capsules have been found in a state of suppuration. 
 
      HENEY    C.    LEA'S
                   (LATE LEA & BLANCHAED'S,)

MEDICAL AND   SURGICAL PUBLICATIONS.
                    TO THE MEDICAL PROFESSION.

  The prices on this Catalogue are those at which these books can generally be
furnished by booksellers, who can readily procure for their customers any which
they may not  have on hand.   Where access to bookstores is  not convenient, I
will forward  them at these prices, free by mail, to any post office in the  Uuited
States.^ In all cases the amount must accompany the order, as accounts are opened
only with dealers; I assume no risks of the  mail, either on the money or the
books, and can  supply nothing but my own publications.  Gentlemen desirous
of purchasing will, therefore, find it more advantageous to deal with the nearest
bookseller whenever practicable, or to send orders through their merchants visit-
ing the larger cities.                                    HENRY C. LEA.
  Philadelphia, February, 1866.

  %* Just issued, a revised Illustrated Catalogue of Medical and Scientific
Publications, forming an octavo pamphlet of 80 large pages, containing specimens
of illustrations,  notices of the medical press, &c. &c.   It has been prepared with-
out regard to expense, and will be found  one of the handsomest  specimens  of
typographical execution as yet presented in  this country.  Copies will be sent to
any address, by  mail, free of postage, on receipt of nine cents in stamps.

  Catalogues of publications in miscellaneous and educational literature forwarded
on application.
  BT" The attention of physicians is especially solicited to the following important new worka
and new editions, just issued or nearly ready:—
   Ashton on the Rectum, new edition,........See page  3
   Brinton on the Stomach,.........."      4
   Bennett on 1 he Uterus, sixth edition,........«      4
   Bowman's Medical Chemistry, lourth edition,......"      4
   Bumstead on Venereal, secoud edition,......."      5
   Barclay on Medical Diagnosis, third edition,   ......"      5
   Brande and Taylor's Chemistry,........."      6
   Dahon's Human Physiology, 3d edition,......."     11
   Dtfnglison's Medical Dictionary, a revised edition, 1865,  ....««     12
   Ellis'Formulary, new edition,........."     13
   Erichsen's System of Surgery, a revised edition,....."     14
   Flint's Practice of Medicine, now ready,......."     15
   Gross's System of Surgery, third edition,......."     ltj
   Gray's Anatomy, Descriptive and Surgical, 2d edition,                   "     17
   Hillier on Skin Diseases,.........."     18
   Hamilton on Fractures and Dislocations, second edition,   .    .    .    .    "     18
   Hodge's Obstetrics,..........."     19
   Pereira's Materia Medica, condensed edition, preparing,                  "     24
   Robeils on Urinary Diseases, nearly ready,......"     24
   Parri^h's Practical Pharmacy, a new edition,......"     25
   Smith on Consumption,.........."     26
   Stille's Therapeutics and Materia Medica, second edition,                 "     27
   Wilson on the Skin,  filth edition,  .        ......."     31
   Wuislow on the Brain and Mind,  second edition,....."     32
   West on Cnildren, fourth edition........."     32
THE  AMERICAN  JOURNAL  OF  THE  MEDICAL  SCIENCES

              AND THE MEDICAL NEWS AND LIBRARY,

   For  FIVE  DOLLARS per annum, invariably in Advance.

  To avoid raising the price at which the " Medical Journal" has been published for nearly fifty
years, subscriptions are now only taken payable in advance.  The result of this policy during 1865
has been a largely increased subscription list, which has exhausted the whole edition printed.  No
copies can be supplied for 1865, and subscriptions can now only be received for I860
   1 
HENRY  C. LEA'S MEDICAL
   The publij-her trusts to be sustained, by an enlarged circulation, in this course, which firives to
 the subscriber,  notwithstanding the enormous advance in the cost of production, nearly fifteen
 hundred large octavo pages for the very moderate price of Five Dollars.


  THE AMERICAN JOURNAL OF  THE MEDICAL  SCIENCES,

                     Edited by  ISAAC  HAYS, M. D.,
 is published Quarterly, on the first of January, April, July, and October. Each number contains
 about two hundred and seventy large octavo pages, handsomely and appropriately illustrated,
 wherever necessary.   It has now been issued regularly for more than forty years, and it has been
 under the control of the present editor  nearly the whole of that period.  Throughout this long
 period, it has maintained its position in the highest rank of medical periodicals both at  home and
 abroad, and has received the cordial support of the entire profession in this country.  Its list of
 Collaborators will be found to contain a large number of the most distinguished names of the pro-
 fession in every section of the United States, rendering the department devoted to

                  ORIGINAL  COMMUNICATIONS
full of varied and important matter, of great interest to all practitioners.
  As the aim of the Journal, however, is to  combine the advantages presented by all  the different
varieties of periodicals, in its

                        REVIEW  DEPARTMENT

will be found extended and impartial reviews of all important new works, presenting subjects of
novelty and interest, together with very numerous

                  BIBLIOGRAPHICAL  NOTICES,
including nearly all the medical publications of the day, both in this country and Great Britain, with
a choice selection of the more important continental works.  This is followed by the

                           QUAKTERLY SUMMARY,

being a very full and complete abstract, methodically arranged, of the

           IMPROVEMENTS AND DISCOVERIES  IN THE  MEDICAL SCIENCES.

  This department of the Journal, so important to the practising physician, is the object of especial
 care on the jpart of the editor.  It is classified and arranged under different heads, thus facilitating
 the researches of the  reader in pursuit of particular subjects, and will be found to present a very
 full and  accurate digest of all observations,  discoveries, and inventions recorded in every  branch of
 medical science.  The very extensive  arrangements  of the publishers are such as to afford to the
editor complete  materials for this purpose, as he not only regularly receives

     ALL  THE  AMERICAN MEDICAL  AND SCIENTIFIC PERIODICALS,

but also twenty or thirty of the more important Journals issued in Great Britain and on the Conti.
 aent, thus enabling him to present in a convenient compass a thorough  and complete abstract of
everything interesting or important to the physician occurring in any part of the civilized world.
  To old subscribers, many of whom have been on the list for twenty or thirty years, the pub-
 lisher feels that no promises  for the future  are necessary; but  those who may desire for the
first time to subscribe, can rest assured that no exertion will be spared to maintain the Journal in
the high position which it has occupied for so long a period.

  By reference to  the terms it will be seen that, in addition to this large amount of valuable and
practical information on every branch of medical  science, the subscriber receives, without further
charge,

            THE  MEDICAL NEWS AND LIBRARY,

a monthly periodical of thirty-two large  octavo  pages.  Its "News  Department" presents the
current information of the day, while the -.Library Department" is devoted to presentirur stand-
                                                ■tary Canal," "Simpson on Females," &c.
   The work at present appearing in its columns, to be completed in 18t>6, is

           CLINICAL OBSERVATIONS ON FUNCTIONAL NERVOUS DISORDERS,

                         By C. Handfield Jones, M.D., F.R.S., <kc.

  As a practical treatise on a class of frequent and intractable diseases, such as Paralyse Em-
lepsy,  Neuralgia, Deimum Tremens, Chorea, Hysteria, &c. &c.: the publisher  believes h'afhe
could not lay before subscribers a more acceptable work.             p        ueueves mat ne

  It will thus be seen that for the small <um of FIVE DOI.T ar«* „-ij:„„j
Will obtain a Quarterly and a Monthly periodical,     DULLARS> Pald ln advance, the subscriber

           EMBRACING ABOUT FIFTEEN HUNDRED LARGE  OCTAVO  PAGES,
  Hemittancs of subscriptions can be mailedat invri«k when arprnflont*. ,- = ».i,   <•     L «
master  th,t th* money is duly inclosed and forwarded                 '  istakenfrom thePost-

                                       Address      HEXRY C. LEA, Philadelphia. 
AND  SCIENTIFIC PUBLICATIONS.
3
                                  ASHTON (T.  J.),
                          Surgeon to the Blenheim Dispensary, &c.

ON  THE  DISEASES,  INJURIES,  AND  MALFORMATIONS  OF  THE
  RECTUM AND ANUS; with remarks on Habitual Constipation.  Second American, from the
  fourth and enlarged London edition.  With handsome illustrations.   In one very  beautifully
  printed octavo volume, of about 300 pages.  $3 25.  (Now Ready.)
  The most complete one we possess on the subject.    Tnia is a. new and carefully revised edition of one
Medico-C kirurgical Review.                   of the most valuable special treatises that the phy-
                                           sician and surgeon can have in his library.—Chicago
  W e are satisfied, after a careful examination of
the volume, and a comparison of its contents with
those of its lead ing predecessors and contemporaries,
t hat the best way for the reader to avail himself of
the excellent advice given in the concluding para-
graph above, would be to provide himself with a
copy of the book from which it has been taken, and
diligently to con its instructive pages.  They may
secure to him m my a triumph and fervent blessing.—
Am. Journal Med. Sciences.
Medical Examiner, Jan.
  The short period which has elapsed eince the ao-
pearance of the former American reprint, and the
numerous editions published in England, are the
best arguments we can offer of the merits, and of
the uselessnesa of any commendation on our part of
a book already so favorably known to our readers.
— Boston Med. and Surg. Journal, Jan 25, 1666.
                             ALLEN  (J.  M.),  M. O.,
                 Professor of Anatomy in the Pennsylvania Medical College, &c.

THE  PRACTICAL ANATOMIST; or, The Student's  Guide  iu the Dissecting.
  ROOM.  With 266 illustrations.  In one handsome royal 12mo. volume, of over 600 pages, extra
  cloth,  %'i 00.   *
  We believe it to be one of the most useful works
upon the subject ever written.  It is handsomely
illustrated, well printed, and will be found of con-
venient size for use in the dissecting-room.—Med.
Examiner.
  However  valuable  may be  the  " Dissector's
Guide*" 'which we, of late, have had occasion to
notice, we feel confident that the work of Dr. Allen
is superior to any of them.  We believe with the
author, that none is so fully illustrated as this, and
the arrangement of the work is such as to facilitace
the labors of the student.  We most cordially re-
commend it to their attention.—Western Lanaet.
                            ANATOMICAL  ATLAS.
By Professors  H.  H.  Smith and W. E.  Horner, of the University of Pennsyl-
  vania.  1 vol. 8vo., extra cloth, with nearly 650 illustrations.   \3T See Smith, p. 26.

               ABEL (F.  A.),  F. C. S. AND C. L. BLOXAM.
HANDBOOK OF  CHEMISTRY,  Theoretical, Practical, and Technical;  with a
  Recommendatory Preface by Dr. Hofmann. In one large octavo volume, extra cloth, of 668
  pages,  with illustrations.  $4 50.

                         ASHWELL  (SAMUEL), M.D.,
                  Obstetric Physician and Lecturer to Guy's Hospital, London.

A. PRACTICAL TREATISE ON THE DISEASES PECULIAR TO WOMEN.
  Illustrated by Cases derived from Hospital and Private Practice. Third American, from the Third
  and revised London edition.  In one octavo volume, extra cloth, of 528 pages.  $3 50.
  The most useful practical work on the subject in I  The most able, and certainly the most  standard
the  English language. — Boston Med.  and Surg. I and practical, work on female diseases that we havs
Journal.                                    I yetseen.—Medico-C kirurgical Review.
                            ARNOTT (NEILL), M. D.
ELEMENTS  OF  PHYSICS;  or  Natural Philosophy, General  and  Medical.
  Written for universal use, in plain or non-technical language.  A new edition, by Isaac Hays,
  M. D.  Complete in one octavo volume, leather, of 484 pages, with about two hundred illustra
  tions.  S3 25.__________________

                     BIRD (GOLDING), A. M.,  M. D.f fee.
URINARY   DEPOSITS:   THEIR   DIAGNOSIS,   PATHOLOGY,  AND
  THERAPEUTICAL INDICATIONS.  Edited by Edmund Lloyd Birkett,  M. D. A new
American, from the last and enlarged London edition. With eighty illustrations on wood.  In one
handsome octavo volume, of about 400 pages, extra cloth.  $3 to.

                         BARLOW (GEORGE  H.), M.D.
                         Physician to Guy's Hospital, London, tec.

A MANUAL OF THE  PRACTICE  OF MEDICINE.  With Additions by D.
  F. Condie, M. D., author of" A Practical Treatise on Diseases of Children," tec.  In one hand-
  some octavo volume, extra cloth, of over 600 pages.  $2 50.
  WerecommendDr.Barlow'sManualinthewarm- I found it clear, eoncise, practical, and sound—Bos-
sat manner as a most valuable vade-mecum. We  ton Med.and Surg. Journal.
have had frequent occasion to consult it, and have |

OITrK, froN THE ETIOLOGY,PATHOLOGY   BLOOD  AND  URINE (MANUALS  ON).  BY
BAND TKKATMBNT OF FIBRO-BRONCHI    J. W  GRIFFITH,  G  O. REESE, AND L.
  tk AND  RHEUMATIC PNEUMONIA.  Ii.   MARKWICK.  One volume, royal liJmo., extra
  one 8vo volume, extra cloth,   pp.150.  *U5.     cloth, with plates,  pp.460. 8125.
i-onniF'S  CLINICAL UKCTLKKS ON  3UR   4EALE ON THE LAWS OF HEALTH IN RF-
'  rKRY   1 vol 8vo. cloth. 350 Pp   81 25      I  LATION TO  MIND  AND BODY.  In one wl.
  UbKV.  i w                              |  royai ujnio., extra cloth,  pp. a%. 30ceet«. 
4                        HENRY C.  LEA'S MEDICAL
                       BUDD (GEORGE), M. D.,  F. ft. S.,
                      Professor of Medicine in King's College, London

ON DISEASES  OF  THE  LIVER.    Third  American,  from the  third  and
  enlarged London edition.   In one very handsome octavo volume, extra cloth, with four beauti-
  fully colored plates, and numerous wood-cuts.   pp. 500.  $4  00.
                                             the text the most striking novelties which have cha-
                                             racterized the recent progress of hepatic physiology
                                             ind pwthology: so thatalthough the size of the book
  Has fairly established for itself a place among the
classical medical  literature of England.—Britisk
and Foreign Medico-Ckir. Review.
  Dr. Budd's Treatise on Diseases of the Liver is
now a standard work in Medical literature, and dur-
ing the intervals which have elapsed between the
successive editions, the author has incorporated into
is not perceptibly changed, the  history of liver dis-
eases is made more complete, and is kept upon a level
with the progress of modern science. It is the best
work on Diseases  of the Liver in any language.—
London Med. Times and Gazette.
       BUCKNILL (J. C),  M. D.,      and    DANIEL^.  TUKE,  M.D.,
Medical Superintendent of the Devon Lunatic Asylum.   Visiting Medical Officer to the York Retreat.

A MANUAL OF  PSYCHOLOGICAL  MEDICINE;  containing the History,
  Nosology, Description, Statistics, Diagnosis, Pathology, and Treatment of INSANITY.  With
  a Plate.  In one handsome octavo volume, of 536 pages, extra cloth.   $4 25.
  The increase  ol mental disease in its various forms, and the difficult  questions to  which it is
constantly giving rise, render the subject one of daily enhanced interest,  requiring on  the part of
the physician a constantly greater familiarity with this, the most perplexing branch of his profes-
sion.   Yet until the appearance of the present  volume there has been for somejrears no work ac
cessible in this country, presenting the results of recent investigations in the Diagnosis and Prog-
nosis  of Insanity, and the greatly improved methods of treatment which have done so much in
alleviating the condition or restoring the health of the insane.
                           BENNETT (HENRY), M. D.
A PRACTICAL  TREATISE  ON  INFLAMMATION  OF THE UTERUS,
  ITS  CERVIX AND  APPENDAGES,  and  on its connection  with Uterine Disease.   Sixth
  American, from the fourth  and revised  English edition.  In one octavo volume, of about 500
  pages, extra cloth. $3 75.  (Just Issued.)
  This standard work, which has done so much to introduce the modern and improved treatment
of female diseases, has received a very careful revision at the hands of  ihe aulhor.  In his preface
he states: "During the past two years this  revision of former 1> bors has been my principal occupa-
tion, and in its present state the work may be considered to embody the matured experience of the
many years I have devoted to the study of  uterine disease."

                   BRINTON  (WILLIAM), M. D   F. R. S.,
                            Physician to St.  Thomas's Hospital.

LECTURES ON THE DISEASES OF THE  STOMACH, with an  introduc-
  tion  on its Anatomy and Physiology.   From the  second and enlarged London edition   With
  illustrations on wood.  In one large and handsome octavo volume.  $3 25.  (Just Rtady.)
  The entire series of lectures embraced in the
volume before us are well worthy of a close study
on the part of every one desirous of acquiring cor-
rect views in relation to the nature  and treatment
of the diseases of the stomach.  Nowhere can be
found a more full, accurate, plain, and instructive
history of these diseases, or more rational  views
respecting their pathology and therapeutics —Ame-
rican Journal of tkt Med. Sciences, April, 18G5.
  This is no mere c< mpilation, no crude record of
caees, but the carefully elaborated production of an
Accomplished physician, who, for many years, has
devoted special attention  to the symptomatology,
pathology, and treatment of gastric  diseases.—
Edinburgh Med. Journal.
  Dr. Brinton's position as a laborer in medical
science and a medical author is fully established,
and these lectures have only added to a reputation
based on many solid grounds.  The work is an im-
portant one, and we argue for it a great |il;ice in
medical literature.—London Lancet, Dec. 3, 16&1.
                          BOWMAN  (JOHN  E.), M.D.

PRACTICAL  HANDBOOK  OF  MEDICAL  CHEMISTRY.   Edited  by C.
  L. Bloxam.  Fourth American, from the fourth and revised English Edition.  In one neat volume,
  royal l2mo., extra cloth with numerous illustrations,  pp.351.  $225.
  Of this well-known  handbook we may say  that
it retains all its < Id simplicity and clearness of ar-
rangement and  description, whilst it has received
from the able edit <r those finishing touches which
the progress of chemistn  has lendi red necessary —
London Med. Times and Gazette, Nov. 29, lfc62.
  Nor is any thing huiriedover, anything shirked ;
open the  book where you will, you find the same
careful treatmentof the subject manifested, anj the
best process for the attainment of the particular ob-
ject in view lucidly detailed and explained.  And
this new edition is not merely a reprint of the last.
With a laudable desire to keep the book up to tne
scientific mark of the present age, every improve-
ment, in analytical method has been introduced.  In
conclusion, we would only say that, familiar from
long acquaintance  with  each page of the  former
issues of this  little book, we gladly  place beside
them another  presenting so many acceptable  im-
provements and additions— Dublin Medical Press.
                                 BY THE SAME AUTHOR.

INTRODUCTION  TO   PRACTICAL  CHEMISTRY,   INCLUDING  ANA-
  LYSIS   Third American, from the  third and revised London edition.  With numerous tllus
  trations   In one neat vol., royal I'imo., extra cloth   ii 25
  This favorite litl'e manual has received a very thorough and careful revision  at the hands ol a
competent editor.and will be found fully brought up to the present condiiion of  chemical science
ilany portions have been rewritten, the subjects ol the blow-pipe and  volumetric analysis have  re-
ceived special attention, and an additional chapter has been appended.   Students of practical chern-
:rtry wiil therefore find it,  as here olore, a most convenicut 8nd condensed text-book  and euide in
the ope ralioBs of the laboratory.                                                     6 
AND SCIENTIFIC  PUBLICATIONS.                   5
                        BUMSTEAD (FREEMAN  J ) M. D.,
      Lecturer on Venereal Diseases at the College of Pnysicians and Surgeons, New York, ice.
THE  PATHOLOGY  AJND  TREATMENT  OF  VENEREAL  DISEASES,
  including the results of recent investigations upon the subject.  Second  edition, thoroughly re-
  vise, d r nd much improved.   With illustrations on wood.  In one very handsome octavo volume,
  of about 700 pages   $5 00  (Just Issued.)
  By far the most valuable contribution to this par-
ticular branch of practice that has seen the light
within the last score of years.  His clear and accu-
rate descriptions of the various forms x>f venereal
d;sease, and especially the methods of treatment he
proposes, are worthy of the highest encomium.  In
these ruspvets it is better adapted for the assistance
of the every-day practitioner than any  other with
which we are acquainted.  In variety of  methods
proposed, in minuteness of direction, guided by care-
(ul discrimination of varying forms and complica
tions, we writedown the book as unsurpassed.  It
is a work which should be  in the possession of every
practitioner.— Chicago Med.  Journal.  Nov. t£61.
  Tne foregoing admirable volume comes to us, em-
bracing the whole subject  of syphilology, resolving
many a doubt, correcting  and confirming  many un
entertained opinion, and in our estimation the best,
eompletest, fullest monogiaph on this subject in our
language.  As far as the author's labors themselves
are concerned, we feel it a duty to say  that  he has
not only exhausted his subject, but he  has presented
to us, without the slightest  hyperbole, the best  di-
rected treatise on these diseases in our language
He has carried its  literature down to the present
moment, and has achieved  his task  in a manner
which cannot but redound to his credit.—British
American Journal,  Oct 1861.
   We believe this treatise will come to be regarded
as high authority in this branch of medical practice,
and we cordially commend it to the favorable notice
of our brethren in the profession.  For  our own part,
we candidly confess  that  we have received nany
new ioeas from its perusal, as well as modified many
views which we have long,  and, as we  now think
erroneously entertained on the subject of  syphilis.
To sum up all in a few words, this book tsone which
no practising physician or medical student can very
well afford to do without.—American Med Times,
Nov. 2, 1861.
  The whole work presents  a complete history of
venereal diseases, comprising mu"h  interesting and
valuable material that has been spread through med-
ical journals within the last twenty years—the pe-
riod of many experiments and investigations on the
subject—the whole carefally digested by the aid of
the author's  extensive personal experience, and
offeied to the profession j,n an admirable form.  Its
completeness is secured by good plates, which are
especially full in the anatomy of the genital org.ins.
We have examined it with great satisfaction, and
congratulate the medical profession in America on
the nationality of a work lhat may fairly be  sailed
original.—Berkshire Med. Journal,  Dec 1*61.
  One thing, however, we are impelled to s*y, that
we have met with  no other book on syphilis, in the
English language, which  gave so full, clear and
impartial views of the important subjects on winch
it treats.  We cannot, however, refrain from ex-
pressing our satisfaction with the full and perspicu-
ous manner in which the subjecthas been presented,
and the careful attention to minute details, so use-
ful—not CO say indispensable—in a practical • reatise.
In conclusion, if we may be  pardoned the use of a
phrase now become stereotyped, but which we heic
employ in all seriousness and sincerity, we do not
hesitate to express the opinion that Dr. Bumstead's
Treatise on Venereal Diseases is a u work without
which no medical library  will  hereafter be consi-
dered complete."—Boston Med. and Surg. Journal
Sept. 5, 1861.
                              BARCLAY (A. W.i, M. D.,
                        Assistant Physician to St. George's Hospital, tec.
A  MANUAL OF  MEDICAL  DIAGNOSIS;  being an Analysis of the Signs
  and Symptoms of Disease.  Third American  from the second and revised London edition.  In
  one neat octavo volume, extra cloth, of 451 pages.  $3 50   (Just Issued)
  The demand for another edition of this work "hows that the vacancy which it attempts to sup-
ply has been recognized by the profession, and that the efforts of the  author to meet the want  have
been successful.  The revision which it has  enjoyed will render it better adapted than before to
afford assistance to the learner in the prosecution of his studies, and to the practitioner who requires
a convenient and accessible manual for speedy reference in the exigencies of his daily duties.  For
this latter purpose it* complete and extensive  Index renders it especially valuable, ollering facilities
for immediately turning to any class of symptoms, or any variety of  disease.
                                                We hope the volume will have  an extensive cir-
                                              culation, not among students of medicine only, but
                                              practitioners also.   They will never regret a faith-
                                              ful study of its pages.— Cincinnati Lancet.
                                                An important acquisition to medical  literiture.
                                              It is a work of high merit, both from the vast im-
  The task of composing such a work is neither an
easy nor a light one; but Dr. Barclay has performed
it in a manner which meets our most unqualified
approbation.  He is no mere theorist; he knows his
work thoroughly, and in attempting to perform it,
has not exceeded his powers.—British Med. Journal.
  We venture to predict that the work will be de-
servedly  popular, and soon become, like Watson's
Practice, an indispensable necessity to  the practi-
tioner.—N. A. Med. Journal.

  An inestimable work of reference for the young
practitioner and student.—Nashville Med. Journal.
por:ance  of the subject upon which it treats, and
also from the real anility displayed in ;*s elabora-
tion.  In conclusion, let us bespeak for this volume
that attention of every student of our art which it
so richly deserves - that place  in every meuical
library which it ca.n  so  well adoru.-  Peninsula*
Medical Journal.
                            8ARTLETT (ELISHA), M. D.
THE  HISTORY,  DIAGNOSIS,  AND  TREATMENT  OF  THE  FEVERS
  OF THE  UNITED  STATES.  A new and revised edition.  By Alonzo Cj.AR.Jt, M. D., Prof.
  of Pathology and Practical Medicine in the N  Y. College of Physicians and- Surgeons, ore.  la
  one octavo volume, of six hundred pages, extra cloth.  Price $4 25.

                             BROWN  (ISAAC  BAKER),
                         Surgeon-Accoucheur to St. Mary's Hospital, &c.
ON  SOME  DISEASES OF WOMEN ADMITTING OF SURGICAL TREAT-
  .VIEjNT.  With handsome illustrations.  One vol. 8vo., extra cloth, pp. 276.  $160
  Mr  Brown has earned f->r himself a high reputa-
tion in the operative treatment of sundry diseases
*nd injuries to which females are peculiarly subject.
We can truly say of his work thnt it is an important
addition  to obstetrical literature.  The operative
suggestions and contrivances which Mr. Brown de-
scribes, exhibit much practical sagacity and skill,
and merit the careful attention of every surgeon-
accoucheur— Association Journal.

  We have no hesitation in recommending this book
to tlte careful attention of all surgeons who make
f»ai»!econipbunt.sa part of their (tady ant1 practice.
 — Uublvn quarterly Journal. 
6                          HENRY  C.  LEA'S  MEDICAL
 BRANDE (WM. T.) D.  C. I-., and  ALFRED S.  TAYLOR, M.  D., F. R. S.
       Of her Majesty's Mint, Sec.             Professor of Chemistry and Medical Jurisprudence in
                                                             Guy'B Hospital.

 CHEMISTRY.   In one handsome 8vo. volume of 696 pages, extra cloth.   $4 50.

  « Having been engaged  in teaching Chemistry in this Metropolis, the one for a period of forty,
 and the other for a period of thirty vears, it has appeared to us that, in spite of the  number of books
 already existing, there was room "for an additional volume, which sht uld be especially adapted tor
 the use of students.   In preparing such a volume lor the press, we  have endeavored  to bear  m
 mind, that the student in the present day has  much to learn, and but a short time at his disposal tor
 the acquisition of this learning."—Authors'Preface.      *
  In reprinting this volume, its passage through the press  has  been superintended by a competent
 chemist, who has sedulously endeavored to secure the accuracy so neces?ary in a work of this
 nature.   No notes or additions have been introduced, but the publishers have bren favored by the
 authors with some corrections  and revisions of the first twenty-one chapters, which have been duly
 inserted.
  In so  progressive a science as Chemistry, the latest work always  has the advantage of presenting
 the subject as modified by the results of the latest  investigations and discoveries.  That this advan-
 tage has been made the most of, and that the  work possesses superior attractions  arising from its
 clearness, simplicity  of style, and lucid arrangement,  are manifested by the unanimous testimony
 of the English medical press.
  It needs no great sagacity to foretell that this book   and  left at the affectation, mysticism, and obscurity
 will be, literally,  the Handbook in Chemistry of the ,  which pervade some late chemical treatises.  Thus
 student and practitioner.  For clearness of language, I  conceived, and worked  out  in the most sturdy, com-
 accuracy of description, extent of information, and i  mon sense method, this book gives, in the clearest and
 freedom  from pedantry  and mysticism of modern   most summary method possible, all the facts and doc-
 chemistry, no other text-book comes into competition !  trines of chemistry, with  more especial reference to
 with it.  The result is a  work which for fulness of]  the wants of the medical  student.—London Medical
 matter, for lucidity of  arrangement, for clearness of   Times and Gazette, Nov. 29, 1862.
style, is as yet without a rival. And long will it be
 without  a rival.   For,  although with the necessary
 advance  of chemical knowledge addenda will be  re-
 quired, there will  be little to take away.  The funda-
mental excellences of the book will remain, preserv-
ing it for years to come, what it now is, the best guide
to the study of Chemistry yet given to the world.—
London Lancet, Dec. 20, 1862.
  Most assuredly, time  has not abated one whit of the
  If we are not very much mistaken, this book will
occupy a place which none has  hitherto held among
chemists; for, by avoiding the errors of previous au-
thors, we have a work which, for its size, is certainly
the most  perfect of  any in  the  English language.
There are several points to be noted in this volume
which separate it widely from any of its compeers—
its wide application, not to the medical student only,
nor to the student in chemistry merely, but to every
fluency, the vigor, and the clearness with whiqh they branch of science, art, or commerce which is in any
not only have composed the work before ns, but have, | way connected with the domain of chemistry.—Lon-
so to say, cleared the ground for it, by hitting right | donMtd. Reoiew, Feb. 1863.
                        BARWELL (RICHARD,) F« R. C.  S.,
                          Assistant Surgeon Charing Cross Hospital, &c.
NA  TREATISE  ON DISEASES  OF THE JOINTS    Illustrated  with engrav-
   ings on wood.  In one very handsome octavo volume, of about  500 pages, extra cloth; $3 00.
  At the  outset we may  state that  the work is
worthy of much praise, and bears evidence of much
thoughtful and careful inquiry, and here and there
of no slight originality  We have already carrnd
this notice further than we intended to do, but not
to the extent the work deserves. We can only add,
that the perusal of it has afforded us great pleasure.
The author has evidently worked  very hard ut his
subject, and his investigations into the Physiology
ing and faithful delineations of disease.—London
Med. Times and Gazette, Feb. 9, 1861.
  This volume will be welcomed, as the record of
much honest research and careful investigation into
the nature and treatment of a most important class
of disorders.  We cannot conclude this notice of a
valuable and useful book without calling attention
to the amount of bona fide work it contains.  It is no
slight matter for a volume to show laborious inves-
and Pathology of Joints have been carried on in a tigatiou, and at the same time original thought, on
manner which  entitles him to be listened to with thBf part'of its  author, whom w e may congratulate
attention and respect.  We must not omit to  men- I on trie Buccessful completion of his arduous task.—
tion the very admirable plates with which the vo- | -
lume is enriched.  We seldom meet with such strik- i
London Lancet, March 9, 1861.
              CARPENTER (WILLIAM  B.), M.  D., F. R. S., &c,
           Examiner in Physiology and Comparative Anatomy in the University of London.

 THE  MICROSCOPE AND  ITS REVELATIONS.    With  an  Appendix con-
   taining the Applications ol the Microscope to Clinical Medicine. &c.  By F. G. Smith, M. D.
   Illustrated by four hundred and thirty-four beautiful engravings on wood.   In one large and very
   handsome octavo volume, of 724 pages, extra cloth, $5  25.
   The great importance of the microscope as a means of diagnosis, and the number of  microsco-
 pjsts who are also physicians, have  induced the American  publishers, with the author's approval, to
 add an Appendix, carefully prepared by Professor Smith, on the applications of ine instrument to
 clinical medicine, together with an  account  of American Microscopes, their modifications  and
 accessories.  This portion of the work is illustrated with nearly one hundred wood-cuts, and it is
 hoped, will adapt the volume more  particularly to the use of the American student.
   Those who  are acquainted with Dr.  Carpenter's   The additions by Prof. Smith  give it a positive
 previous writings on Animal and Vegetable Physio- I claim upon the profession,  for which we doubt not
 logy, willfully understand how vasta store of know- j he  will receive their sincere thanks.  Indeed we
 ledge he is able to bring to bear upon go comprehen- I know not where the student of medicint will 'find
 sive a subject as the revelations of the microscope; such a complete and satisfactory collectiot of micro-
 and even those who have no previous acquaintance ; scopic facts bearing upon physiology and Dractical
 with the construction or  uses  of this  instrument, : medicine as is contained in  Prof. Smith's appendix •
 will find abundanceof information conveyed in clear ' and this of itself, it seems to us. is fulU worth the
uld  simple lauguagc—AZed. Times  and Gazette, cost of the volume— Louisville Medica Review 
AND SCIENTIFIC  PUBLICATIONS.                  7
                CARPENTER(WILl_IAM B.>,  M.D., F. R. S.,
          Examiner in Physiology and Comparative Anatomy in the University of London.

PRINCIPLES OF HUMAN PHYSIOLOGY;  with  their chief applications  to
  Psychology, Pathology, Therapeutics, Hygiene, and Forensic Medicine. A new American, from
  the last and revised London edition.  With nearly three hundred illustrations.  Edited, with addi-
  tions, by Francis Gurney Smith, M. D., Professor of the Institutes of Medicine in the Pennsyl-
  vania Medical College, &c. In one very large and beautiful octavo volume, of about nine hundred
  large pages, handsomely printed, extra cloth, $5 CO

  For upwards of thirteen years Dr. Carpenter'si  To eulogize thisgreatwork would be superfluous.
work has been considered by the profession gene- *We should observe, however, that in this edition
rally, both in this country and England, as the most  the author has remodelled a large  portion  of  tha
valuable compendium on the subject of physiology  former, and the editor has added much matter of in-
in our language. This distinction it owes to the high  terest, especially in the form of illustrations. We
attainments and unwearied industry  of its accom-  ; may confidently recommend it as the most complete
plished author.  The present edition (which, like the  ' work  on  Human Physiology  in our language.—
iast) American one, was prepared by the author him-  I Southern Med. and Surg. Journal.
self), is the result of such extensive revision that it    The mogt  complete  work on the science in  our
may almost be considered a new work.   We need  | ,        _4m Med. Journai.
hardly say, in concluding this brief notice, that while   J;,           ,
the work is indispensable to every student of medi-1  The mo_st completework now extant in our lan-
cine in this country, it will amply repay the practi-
tioner for its perusal by the interest and value of its
contents.—Boston Med. and Surg. Journal.
guage.—N. O. Med. Register.
  This is a standard work—the text-book used by all
medical students who read the English  language.
It has passed through several editions in order to
keep pace with the rapidly growing science of Phy-
siology.  Nothing need be said in its praise, for its
merits are universally known; we have nothing to j Human Physiology.  His former editions have for
say of its defects, for they only appear where the  many years been almost the only text-book on Phy-
science of which it treats is incomplete.—Western! siology in all our  medical schools, and its circula-
  The best text-book in the language on this ex
tensive subject.—London Med. Times.
  A complete cyclopaedia of this branch of scienc*.
—N. Y. Med. Times.
  The profession of this country, and perhaps also
of Europe, have anxiously and for some time awaited
the announcement of this new edition of Carpenter s
  The most complete exposition of physiology which
any language can at present give.—Brit, and For.
Med.-Ckirurg. Review.

  The greatest, the most reliable, and the best book
tion among the profession has been unsurpassed by
any work in any department of medical science.
  It is quite unnecessary for us to speak of this
work as its merits would justify.  The mere an-
nouncement of its appearance will afford the highest
pleasure to every student of Physiology, while its
oa the subject which we know of in the English ■ perusal will be of  infinite  service in  advancing
language.—Stethoscope.                        < physiological science.—Ohio Med. and Surg. Journ
                                  BY THE SAME AUTHOR.

ELEMENTS (OR MANUAL) OF PHYSIOLOGY,  INCLUDING PHYSIO-
  LOGICAL ANATOMY.  Second American, from a new and revised London edition.   With
  one hundred  and  ninety illustrations.  In one very handsome octavo volume, leather,  pp. 566.
  $4 00.
  In publishing the first edition of this work, its title was altered from that of the London volume.
by the substitution of the word "Elements" for that of " Manual," and with the author's sanction
the title of " Elements" is still retained as being more  expressive of  the scope of the treatise.

                                  BY THE SAME AUTHOR.

PRINCIPLES  OF  COMPARATIVE PHYSIOLOGY.  New  American,  from
  the  Fourth and Revised London edition.  In one large and handsome octavo volume, with over
  three hundred beautiful illustrations,  pp. 752.  Extra cloth, $5 00
  This book should not only be read but thoroughly
studied by every member of the profession. None
are too wise or old, to be benefited thereby.  But
especially to the younger class would we cordially
commend it as best fitted of any work in the English
language to qualify them for the reception and coin-
prehension of those truths which are daily being de-
veloped in physiology.—Medical Counsellor.
  Without pretending to it, it is an encyclopedia of
the subject, accurate and complete in all respects—
a truthful reflection of the advanced state at which
the science has now arrived.—Dublin Quarterly
Journal of Medical Science.
  A truly magnificent work—in itself a perfect phy-
siological study.—Ranking's Abstract.
  This work stands without its fellow.  It is one
few men in Europecould have undertaken;  it is one
no man, we believe, could have brought to so suc-
cessful an issue as Dr. Carpenter.  It required for
its production a physiologist at once deeply read in
the  labors of others, capable of taking a general.
critical, and unprejudiced view of those labors, and
of combining the varied, heterogeneous, materials at
his  disposal,  so as to form an  harmonious whole.
We feel that this abstract can give the reader a very
imperfect idea of the fulness of this work, and no
idea of its unity, of the admirable maj ner in which
material has  been brought, from the most various
sources, to conduce to its completeness, of the lueio-
ity of the reasoning it contains, or of the clearness
of language in which the whole is clothed.  Not the
profession only, but the scientific world at large,
must feel  deeply indebted to Dr. Carpenter for this
great work.  It must, indeed, add  largely even to
his high reputation.—Medical Times.
                            BY THE SAME AUTHOR.  (Preparing.)

PRINCIPLES  OF  GENERAL  PHYSIOLOGY,  INCLUDING  ORGANIC
  CHEMISTRY AND  HISTOLOGY.  With a General  Sketch ol  the Vegetable and Animnl
  Kingdom.  In one large and very handsome octavo volume, with several hundred illustrations.

                                  BY THE SAME AUTHOR.

A PRIZE ESSAY ON THE USE OF ALCOHOLIC LIQUORS EN  HEALTH
  AND DISEASE.  New edition, with a Preface  by D. F. Condie,  M  D.,  and  explanation* of
  scientific words.  In one neat 12mo. volume, extra cloth  pp. 178.   60 cents. 
8                        HENRY  C. LEA'S  MEDICAL
                           CONOIE  ID.FJ, M.D., fcc.

A  PRACTICAL TREATISE  ON  THE  DISEASES OF CHILDREN.   Fifth
  edition, revised and augmented   fn one large volume, 8vo., extra cloth, of ovvrlW pages. $4 50
  In presenting a new and revised edition of this favorite work, the publishers have only to state
that the author has endeavored to render it in every respect "a complete and faithful exposition of
the pathology and therapeutic> of the  maladies incident to the earlier  stages of" existence—a full
and exact account of the diseases of infancy and childhood."  To accomplish this he has subjected
the whole work  to a careful and thorough revision, rewriting a considerable portion, and adding
several new chapters. In  this manner it  is hoped that any deficiencies which may have previously
existed have been supplied, that the recent labors of practitioners and observers have been  tho-
roughly incorporated, and that in every point the*work will be found to maintain the high reputation
it has enjoyed as a complete and thoroughly practical book of reference in infantile affections.
  A few notices of previous editions are subjoined.
  Dr. Condie's scholarship, acumen, industry, and
practical sense are manifested in this, as in all his
numerous contributions to science.—Dr. Holmes's
 Report to the American Medical Association
  Taken as a whole, in our judgment, Dr. Condie's
 Treatise  is the one from  the perusal of which the
 practitioner in this country will rise with the great-
 est  satisfaction.— Western Journal of Medicine and
 Surgery.
  One of the best works upon the Diseases of Chil-
 dren in the English  language.—Western Lancet.
  We feel assured  from actual experience that nc
 physician's library  can be  complete without a copy
 of this work.—JV V. Journal of Medicine.
  A veritable pediatric encyclopaedia, and an honoi
 to American medical literature.—Ohio Medical ana
 Surgical Journal.
  Wefeel persuaded thatthe American medical pro-
fession will soon regard it  not only as a very good, (yield an unhesitating concurrence.—Buffalo Med
but  as the vert best "Practical Treatise on the \Tournal.
Diseases of Children."—American Medical Journal    Perhaps the most full and complete work now be-
  In the department of infantile therapeutics, the ore the profession of the United States; indeed, wfl
 work of Dr.  Condie is considered one o( the best nay say in the English language.  It is vastly supe-
 which has been published in the English language, rior tomostof its predecessors.—Transylvania Med.
 —The Stetkoscope.                            \Journal
  We pronounced the first edition to be the best
work on the diseases of children in the English
language, and, notwithstanding  all that has lieen
published, we still regard it in that light.—Medical
Examine r
  The value of works by native authors on the dis-
eases which the physician is called upon to combat,
will be appreciated by all j  anil the work of Dr. Con-
die has gained for itself the character of a safe guide
lor students, and a useful work for consultation by
those engaged in practice.—iV. Y  Med  Times.
  This is the fourth edition of this deservedly popu-
lar treatise.  During the interval since the last edi-
tion, it has been subjected to a thorough  revision
by the author;  and all new observations in the
pathology and therapeutics of children  have been
included in the present volume.  As we said btfore,
we do not know of a better book tin diseases of chil-
dren, and to a large part of its recommendations we
            CHRISTISON  (ROBERT), M. D.,  V. P. R. S. E., &.C.

A  DISPENSATORY;  or.  Commentary on  the Pharmacopoeias of  Great Britain
  and the United States; comprising the Natural History, Description, Chemistry, Pharmacy, Ac-
  tions, Uses, and Doses of the Articles of the Materia Medica.  Second edition, revised and im-
  proved, with a Supplement containing the most important New Remedies.  With copious Addi-
  tions, and two hundred and thirteen large wood-engravings.  By R. Eolesfeld Griffith, M. D.
  In one very large and handsome octavo volume, extra cloth, of over 1000 pages.  $4 CO
                       COOPER (BRAIMSBY  BJ, F. R. S.
LECTURES  ON  THE  PRINCIPLES  AND  PRACTICE  OF  SURGERY.
  In one very large octavo volume, extra cloth, of 750 pages.  $2 00.
COOPER ON THE ANATOMY AND DISKASE8
  OP THE BREAST, with twenty-five Miscellane-
  ous and Surgical Papers.  One large volume, im-
  perial tsvo.,  extra cloth, with 252 figures, on 36
  plates.  S3 00.
COOPER  ON THE  STRUCTURE AND DIS-
  EASES  OF THE  TESTIS, AND  ON THE
  THYMUS GLAND.  One  vol. imperialevo., ex-
  tra cloth, with 177 figures on 29 plates.  82 SO.
iCLYMER ON FEVERS;  THEIR DIAGNOSIS,
|   PATHOLOGY, AND  TREATMENT.  In one
I   octavo volume, leather, of 600 pages  $1 75.
 COLOMBAT DE L'ISERE ON THE DISEASES
   OF FEMALES, and on the special Hygiene of
   their Sex.  Translated, with many Notes and Ad-
   ditions, by C. D.  Mbigs, M.D.  Second edition.
   revised and unproved.   In one  large volume, oc-
   tavo, leather, with numerous wood-cuts,  dd 780
   S3 75.                               rr
                           CARSON  (JOSEPH),  M. D.,
           Professor of Materia Medica and Pharmacy in the University of Pennsylvania.

SYNOPSIS  OF  THE COURSE OF  LECTUREb  ON MATERIA MEDICA
  AND PHARMACY, delivered in the University of Pennsylvania   With three Lectures'on
  the Modus Operandi of Medicines.  Third edition, revised.  In one handsome octavo volume
  $2 o0.
                          CURLING  (T.  B.), F. R.S.,
             Surgeon to the London Hospital, President of the Hunterian Society Sec
A PRACTICAL  TREATISE  ON  DISEASES OF THE TESTIS, SPERMA
  TIC  CORD, AND SCROTUM. Second American, from the second and enlarged Engli8fl edi-
  Hon.   In one handsome octavo volume, extra cloth, with numerous illustrations  pp 420. 92 00 
AND SCIENTIFIC  PUBLICATIONS.                   9
               CHURCHILL (FLEETWOOD),  M. D., M. R. I. A.
ON THE THEORY AND PRACTICE  OF MIDWIFERY.   A new American
  from the fourth revised and enlarged London edition.  With Notes and Additions, by D. Francis
  Conbie, M.  D., author of a '(Practical Treatise on the  Disease* of Children," fee  With 194
  illustrations.  In one very handsome octavo volume of nearly 700 large pages, extra cloth, %4 00.
  This work has been so long an established favorite, both as a text-book tor the learner and as a
reliable aid in consultation lor the practitioner, that in presenting a new edition it is only necessary
to call attention to the very extended improvements which it has received   Having had the benefit
of two revisions by the author since the last American reprint, it has been materially enlarged, and
Dr. Churchill's well-known conscientious  industry is a guarantee that every portion has been tho-
roughly brought up with the latest results  of European investigation in all departments of the sci-
ence and art of obstetrics.  The recent dale of the last Dublin edition has not left much ol  novelty
for the American editor to introduce, but he has endeavored to insert whatever has since appeared,
together with such matters as his experience has shown him would be desirable for the  American
student, including a large number of illustrations   With the sanction of the author he  has added
in the form of an appendix, some chapters from a little "Manual  for Midwive* and Nurses," re-
cently issued by Dr. Churchill, believing 'hat the details there presented can hardly fail to prove ol
advantage to the junior practitioner.  The result of all these auditions is that the work  now con-
tains  fully one-half more matter than the  last American edition, with nearly one-half more illus-
trations, so that notwithstanding the use of a smaller type, the volume contains almost  two hundred
pages more than before.
  No effort has been spared to secure an improvement in  the mechanical execution  of the work
equal to that which  the text has received, and  the volume is confidently presented as  one of the
handsomest that has thus far been laid before the American profession; while the very low price
at which it is offered should secure for it a place in every lecture-room and on every otfice table.
  A better book in which to learn these important
points we have not met than Dr. Churchill's. Every
page of it is full of instruction j  the opinion of all
writers of authority is given on questions of diffi-
culty, as well as the directions and advice of the
learned author himself, to which he adds the result
of statistical inquiry, putting statistics in their pro
per place and giving them tlieir due weight, and no
more.  We have never read a book more free from
professional jealousy than Dr. Churchill's.  It ap-
pears to be written with the true design of a book on
medicine, viz: to give all that is known on the sub-
ject of which he treats, both theoretically and prac-
tically, and to advance such opinions of his own as
he believes will benefit medical science, and insure
the safety of the patient.  We have said enough to
convey to the profession that this book of Dr. Cnur-
eaill's  is admirably suited for a  book  of reference
for the practitioner, as well as a text-book for the
student, and we hope it may be extensively pur-
chased amongst our  readers.  To them we most
strongly recommend  it. — Dublin  Medical  Press

  1fc bestow praise on a  book that has received such
marked approbation would be superfluous.  We need
only say,  therefore, that if the first edition was
thought worthy of a favorable reception by the
medical public, we can confidently affirm  that this
will be found much more  bo.  The lecturer, the
practitioner, and the student, may all have recourse
to its pages, and derive from their perusal much in-
terest and instruction in everything relating to theo-
retical  and practical midwifery.— Dublin Quarterly
Journal of Medical Science
  A. work of very great merit, and such as we can
gonfidently recommend to the study of every  obste-
tric practitioner.—London Medical  Gazette.
  Few treatises will  be found better adapted as t
text-book for the student,  or as a manual for th
frequent consultation of the young practitioner.-
American  Medical Journal.
  Were we reduced to the necessity of having but
me work  on midwifery, and permitted  to choose,
ve would unhesitatingly take Churchill.—Western
Med. and Surg. Journal.
  It  is impossible to conceive a more useful  and
:legant  manual  than Dr. Churchill's Practice of
Vliawifery.—Provincial Medical Journal.
  Certainly, in our opinion, the very best work on
ae subject which exists.—N. Y. Annalist.
  No work holds a higher position, or is more de-
serving of being placed  in the hands of the tyro,
the advanced student, or the practitioner.—Medical
Examiner
  Previous editions  have been received witt mark-
ed favor, and they deserved it;  but this, reprinted
from a very late Dublin edition, carefully revised
and brought up by the author to the present time,
does present an unusually accurate and ablt  expo-
sition of every  important particular embraced in
the departmentof midwifery.  * *   The clearness,
directness, and  precision of its teachings, together
with the great amount of statistical  research which
its text exhibits, have served to place it already in
the foremost rank-of works in this department of re-
medial science.— rV O Med  and Sure-  Tnurnal.
   In our opinion, it forms one ol the best if not t e
very best text-book and epitome of obstetric science
which we at f resent possess in the English  lan-
guage.— Monthly Journal of Medical Science.
   The clearness and precision of style in which it is
written, and the greatamountof statistical researeh
which it contains, have served to place it in the first
rank of works in this departmentof medical science.
— N. Y. Journal of Medicine.
   This is certainlythe most perfect system extant.
 it is the  best adapted for the purposes of a text-
 )ook, and that which he whose necessities confine
 lim to one book, should  select in preference to all
 ithers.—Southern Medical and Surgical Journal.
                                   BY THE SAME AUTHOR

ON THE  DISEASES OF INFANTS  AND  CHILDREN.   Second  American
  Edition, revised and enlarged by the author. Edited, with Notes, by W. V. Keating, M. D.  Id
  one large and handsome volume, extra cloth, of over 700 pages.  $4 50.
  In preparing this work a second time for the  American profession, the authos  has spared no
labor in giving it a very thorough revision, introducing several new chapters, and rewriting others,
while every .portion of the volume has  been subjected to a severe scrutiny.  The effort- of the
American editor have been directed to supplying such  information relative to matters  peculiar
to this  country  as might have escaped the attention of the author,  and the whole  may, there-
fore be safely pronounced one of the most complete works on the subject accessible to the Ame-
rican Profession.   By an  alteration in  the size of the page, the«e very extensive  additions  have
been accommodated without unduly increasing the size of the work.

                                   BY THE SAME AUTHOR.

ESSAYS ON  THE  PUERPERAL FEVER, AND  OTHER  DISEASES  PE-
  CULIAR TO  WOMEN.  Selected from the writings of British Authors previous to ihe close of
  tte Eighteenth Century.  In one neat octavo volume, extra cloth, of about 450 pages  $2 50. 
10                        HENRY  C.  LEA'S  MEDICAL
           CHURCHILL  (FLEETWOOD),  M. D., M. R. ». A.,  Sec.
ON THE DISEASES  OF  WOMEN;  including  those of Pregnancy and  Child-
  bed. A new American edition, revised by the Author  With Notes and Additions, bv D Fran-
  cis Condik, M. D., author ol." A Practical Treatise on the Diseases of Children."  With nume-
  rous illustrations.  In one large  and handsome octavo volume, extra cloth, of 768 pages. $4 00.
  This edition of Dr. Churchill's very popular treatise may  almost  be  termed a new work, so
thoroughly has he revised it in every portion.   It will be found greatly enlarged, and completely
brought up to the most recent condition of the subjeot, while the very handsome series of illustra-
tions introduced, representing such pathological conditions as can be accurately portrayed, present
a novel feature, and afford valuable assistance  to the young practitioner.  Such additions as ap-
peared desirable for the American student have been  made  by the  editor, Dr. Condie, while n
marked improvement in the mechanical execution keeps pace with the advance in all other respects
which the volume has undergone,  while the price has been kept at the former very moderate rate.
  It comprises, unquestionably, one of the most ex- | extent that Dr. Churchill does.  His, indeed, is the
only thorough treatise we know of on the subject J
and it may be commended to practitioners and stu-
dents as a masterpiece in its particular department.
—Th> Western Journal of Medicine and Surgery.
  As a comprehensive  manual for  students, or  a
work of reference for practitioners, it surpasses any
other that has ever issued on the same subject front
the British press.—Dublin Quart. Journal.
act and comprehensive expositions of the present
state of medical knowledge in respect to the diseases
of women that has yet been published.—Am. Journ.
Med. Sciences.
  This work is the  most reliable which we possess
on this subject; and is deservedly popular with the
profession.—Ckarleston Med. Journal, July, 1857.
  We know of no author who deserves that appro-
bation, on "the diseases of females," to the same

                             DICKSON  (S.  H.),  M. D.,
          Professor of Practice of Medicine in the Jefferson Medical College, Philadelphia.

ELEMENTS  OF MEDICINE;  a Compendious View of  Pathology and Thera-
  peutics, or the History and Treatment of Diseases.  Second edition,  revised.  In one large and
  handsome octavo volume of 750 pages, extra cloth.  $4 00.
   The steady demand which has so soon exhausted the first edition of this work, sufficiently shows
that the  author was  not mistaken in supposing that a volume  of this  character was needed—an
elementary manual of practice, which should present the leading principles of medicine with  the
practical results, in a condensed  and perspicuous manner.  Disencumbered of unnecessary detail
and fruitless speculations, it embodies what is most requisite for the student to learn, and at  the
same time what  the active practitioner wants when obliged, m the daily calls of his profession, to
refresh his memory on special points.  The clear and attractive style  of the author renders  the
whole easy of comprehension, while his long experience gives to his teachings an authority every-
where acknowledged.  Few physicians, indeed, have had wider opportunities for observation and
experience, and  few. perhaps, have used them to better purpose  As the result of a long  life  de-
voted to  study and practice, the present edition, revised and brought up  to the date  of publication,
will doubtless maintain the reputation already acquired  as a condensed and convenient American
text-book on the  Practice of Medicine.
                     DRUITT (ROBERT), M.R. C.S., Sec.
THE PRINCIPLES  AND PRACTICE  OF  MODERN  SURGERY.   A new
  and revised American from the eighth enlarged and improved London edition.  Illustrated with
  four hundred and thirty-two Wood-engravings.  In one very handsomely printed octavo volume
  of nearly 700 large pages, extra cloth, $4 00.
  A work which like Druitt's Surgery hns for so many years mamlamed the position of a lead-
 ing favorite with all classes of the profession, needs no special recommendation to attract attention
 to a revised edition.  It is only necessary to state that  the author  has spared no pains to keep the
 work up to its well earned reputation of presenting in a small and convenient compass the latest
 condition of every department of surgery, considered both as a science and as an art; and that the
 services of a competent American editor have been employed to introduce whatever novelties may
 have escaped the  author's attention, or may prove of service to the American  practitioner.  As
 several editions have appeared in London ^since the issue of the last American  reprint, the volume
 has had the benefit of repeated revisions  by the author, resulting in a very thorough alteration and
 improvement.  The extent of these additions may be estimated from the fact that it now contains
 about one-third more matter than the previous American edition,  and that notwithstanding the
 adoption of a smaller type, the pages have been increased by about one hundred,  while nearly two
 hundred and fifty wood-cuts have been added to the former list of illustrations.
  A marked improvement will also be perceived in the mechanical and artistical execution of the
 work, which, printed in the best style, on new type, and fine paper, leaves little to  be desired as
 regards external finish; while at the very low price affixed  it will  be found  one of the cheapest
 volumes accessible to the profession.
  This popular volume, now a most comprehensive ! nothing of real practical importance has been omit-
 workon surgery, has undergone many corrections, | ted; it presents-a faithful epitome of everything re-
 improvements, and additions, and tbe principles and j lating t > surgery up to the present hour.   It is dc-
 the practice of the art have been brought down to servedly a popular manual, both with the student
 the latest record and observation. Of the operations I and practitioner.—London Lancet, Nov. 19 1859.
 in surgery it iB impossible to speak too highly. The I  .   .   .   ,....,
 descriptions are so clear and concise, and the illus-   'J1 closing this brief notice, we recommend as cor-
 trations so accurate and numerous, that the Btudent I ?IaHv.as £ver,'hls m08t U8eful and comprehensive
 can have no difficulty, with instrument in hand, and | hand-book,  it must prove a  vast assistance, not
 book by his side, over the dead body, in obtaining | only to the student of surgery,  but also to the busy
 a proper knowledge and sufficient tact in this much practitioner wht may not have the leisure to devota
 ceglecteddepartmentofmedicaleducation.—British , ^lms.plt  J.™?""1' of more lengthy volumes—
 and Foreign Medico-Chirurg. Review. Jan. 1S60    London Med. Times and Gazette, Oct. 93, 1859
  In the present edition the author has entirely re- !  In  a word, this  eighth edition of Dr  Druitt'j
 written many of the chapters, and has incorporated  Manual of Surgery is all that the surgical student
 the various improvements and additions  in modern or practitioner could  desire. — Dublin  Quarterly
•orgery.  On carefully going over it, we find that Journal of Med. Sciences, Nov. 1&59. 
AND SCIENTIFIC  PUBLICATIONS.                  11
                            DALTON, JR.  (J. C), M.  D.
                 Professor of Physiology in the College of Physicians, New York.

A  TREATISE ON  HUMAN  PHYSIOLOGY, designed for the use of Students
  and Practitioners of Medicine.  Third edition, revised, with nearly three hundred illustrations
  on wood.  In one very beautiful octavo volume, of 700 pages, extra cloth, $5 25.  (Just Issued.)

  The rapid demand for another edition  of this work sufficiently shows that the author has suc-
ceeded in his efforts  to produce a text-book of standard and permanent value, embodying within
a moderate  compass all that  is definitely and positively  known within the domain of Human
Physiology.  His high reputation as an original  observer and investigator,  is a guarantee  that in
again revising it he has introduced whatever is necessary to render it thoroughly on a level with
the advanced science of the day, and  this has been accomplished without unduly increasing  the
size of the volume.
  No exertion has  been spared to maintain the high standard of typographical execution which has
rendered this work admittedly one of the handsomest volumes as yet produced in this country.
  It will be seen, therefore, that  Dr, Dalton's best \  own original views and experiments, together with
efforts have been directed towards perfecting his  a desire to supply what he considered some deficien-
work. The additions are marked by the same fea-   cies in the first edition, have already made the pre-
tures which characterize the remainder  of the vol-   sent one a necessity, and it  will no doubt be even
ume, and render  it by far the most desirable text- j more eagerly sought for than the first.  That it is
book  on physiology to place in  the hands of the  not merely a reprint, will be seen from the-author's
student which, so Car as we  are aware, exists  in ' statement of  the following principal additions and
the English language, or perhaps in any  other.  We ' alterations which he has made.  The present, like
therefore have no hesitation in recommending Dr. i the first edition, is printed in the highest style of the
Dalton's book for the classes for which it is intend- j printer's art, and the illustrations are truly ndmira-
ed.  satisfied as we are that it is  better  acapted  to  ble tor their clearness in expressing exactly what
their uee than any other work of the kind to which  their author intended.— Boston Medical and Surgi-
they have access.—American  Journal of the Med.  cal Journal, March 28, 1861.

        '   P  »     •                            '   It is unnecessary togive a detail of theadditions;
  It is, therefore, no disparagement, to the many  suffice it to say, that they are numerous and import-
books upon physiology, most excellent in their day,  ant, and such as will  render the work still more
to say that Dalton's is the only one that gives us the  valuable and acceptable to the profession as a learn-
science as it was known to  the best philosophers  ed and c iginal treatise on this all-important branch
throughout thelworld, at the beginning  of the cur- , of mtJicine.  All that was said in commendation
rent year.  It states in comprehensive but concise | of the getting up of the first edition, and the superior
diction, the  facts established by experiment,  or j style of the  illustrations, apply with equal force to
other method of demonstration,  and details, in an ] this.  No better work on physiology can be placed
understandable manner, how it is done, but abstains ' in the hand of the student.—St. Louis Medical and
from thediscussion of unsettled or theoretical points. I Surgical Journal, May, 1861.
Herein it is unique; and these characteristics ren  j   These additions, while tes:ifying to the learning
der it a text-book without  a  rival, for  those who  and industry of the authoT, render the book exceed-
desire to study physiological science as it is known | ingiy useful, as the most complete expose of a sci-
to its most successful  cultivators. And  it isphysi- I encej 0[ wnich Dr. Dalton  is doubtless the ablest
ol.igy thus presented that lies at the foundation  of | representative on this side of the Atlantic—New
correct pathological knowledge;  and this in turn is ; Orleans Med  Times, May, 1861.
the  basis of rational therapeutics: so that patholo-i   .       ,  ...     , ., .  ,       .,      .       .
gy,  in fact, becomes  of prime importance in the  . A second edition of this deservedly popular work
                                   .-..-•     having been called for in the short space of two
proper discharge of our every-day practical duties.
—Cincinnati Lancet, May, 1861.

  Dr. Dalton needs no word of praise from us. He
                                                years, the author has supplied deficiencies, which
                                                existed in the former volume, and has thus  more
                                                completely fulfilled his design of presenting to the
is universally recognizea as among the first, if not  profession a reliable and precise text- book, and one
the veryfiist, of American physiologists now living, j which we consider the best outline on the subject
The first edition of his admirable work appeared but . of which it treats, in any language.—N. American
two years since,  and the advance of science, his  Medico-Chirurg.  Review, May, 1661.
           DUNGLISON,  FORBES,  TWEEDIE,  AND CONOLLY.

THE  CYCLOPAEDIA OF  PRACTICAL MEDICINE:  comprising Treatises on
  the Nature and Treatment of Diseases, Materia Medica, and Therapeutics, Diseases of Women
  and  Children, Medical Jurisprudence, &c. &c.   In four large  super-royal octavo volumes, of
  3254 doubte-columr.ed pages, strongly and handsomely bound, with raised bands.  $15 00.
  *** This work contains no less than four hundred and eighteen distinct treatises, contributed by
eixty-eight distinguished physicians, rendering it a  complete library of reference for the country
practitioner.
  The most complete work on Practical Medicine
axtant; or, at least,  in our  language.—Buffalo
Medical and Surgical Journal.

  For reference, it is above all price to every prac-
titioner.— Western Lancet.
  One of the most valuable medical publications of
the day—as a work of reference it is invaluable.—
Western Journal of Medicine and Surgery.
  The editors are practitioners of established repu-
tation, and the list of contributors embraces many
of the most eminent professors and teachers of Lon-
don, Edinburgh, Dublin, and Glasgow.  It is, in-
deed, the great merit ol this work that the principal
articles have been furnished by practitioners who
have not only devotee especial attention to the dis-
eases about  which they have written, hut have
also enjoyed opportunitiei  for an extensive practi-
cal  acquaintance with them and whose reputation
carries the assurance of their competency justly to
  It has been to us, both as learner and teacher, a
work for ready and frequent reference, one in which  appreciate the opinions o< others, while it stamps
modern  English medicine is exhibited in the most j their own doctnr.es witl high and just authority.—
advantageous light.—Medical Examiner.          I American Medical Journal.
OEWEES'S COMPREHENSIVE SYSTEM OF
  MIDWIFERY.  Illustrated  by occasional  cases
  and many engravings.  Twelfth edition, with the
  author's  last improvements and  corrections  In
  oneoctavovolume, extracloth,of600pages $350.
DJBWEES'S TREATISE ON THE PHYSICAL
  AND MEDICAL TREATMENT  OF  CHILD
  REN.  The last edition   In one volume, octavo,
  extra cloth, 548 pages   S2 80
OEWEES'S TREATISE  ON  THE DISEASES
  OF  FEMALES  Tenth edition  In one volume,
  octavo extra cloth, 532 pages, with plates  S3 00. 
12                         HENRY-  C.  LEA'S  MEDICAL
                         DUNGLISON  (ROBLEY),  M.D.,
          Professor nf Institutes of Medicine in the Jefferson Medical College. Philadelphia
      ENLARGED AND REVISED  EDITION  OF 1865—,[ Just Issued.)

MEDICAL  LEXICON; a Dictionary  of Medical Science, containing a  concise
  Explanation of the various Subjects and Terms  of Anatomy, Physiology, Pathology, Hygiene,.
  Therapeutics Pharmacology. Pharmacy, Surgery, Obstetrics, Medical Jurisprudence, and Den-
  tistry.  Notices of Climate and of Mineral Waters; Formula: for Officinal, Empirical, and Dietetic
  Preparations;  with the Accentuation and Etymology of the Terms, and the French and other
  Synonymes; so as to constitute a French as well as  English  Medical Lexicon.  Thoroughly
  revised and very greatly modified  and augmented.   In one  very large and  handsome royal
  octavo volume, of 1048 double-columned pages, in small type, strongly done up in extra cloth,
  $rj 00; leather, raited bands, $6 75
                               Preface to the New Edition
  " The author has again  been required to subject his Medical Lexicon to a thorough revision.
The progress  of Medical Science,  and the consequent introduction of new subjects and  terms,
demanded this; and  he has embraced  the occasion  to render more complete the etymology and
accentuation of th< terms.  On no previous revision ha* so much time and labor been expended by
him.   Some idea may be formed of this, from the fact,  that although the page has  been augmented
in all its dimensions, not fewer than between sixty  and  seventy pages have been added.
  "A- the author has remarked on former occasions, it has ever been his ardent wish to make the
work a salislactorvand desirable—if not indispensable—lexicon, in whi';h the inquirer may search,
without disappointment, for every term  that has been legitimated in thenomenclatu  e of the science;
and he confidently presents this edition  as having more  claims on the attention of  the praeiitioner
and student than its predecessors.
   ' Once more the author gladly seizes  the opportunity afforded him to express hisgrateful acknow-
ledgments for (he vast amount of favor  which has been extended to the Dictionary."
    January, l!sb5.
  The object of the author from the outset has not  been to  make the work a mere lexicon or dic-
tionary of terms, but to afford, under each a condensed view of its various medical relations, and
thus to render the work an epitome of the existing condition of medical  science.  Starting with
this view, the immense demand whico  has existed  for the work has enabled him, in  repeated re-
visions, lo augment its completeness and usefulness, until  at length it has attained the position of
a recognized and standard  authority wherever the language is spoken.  This has only  been accom-
plished by the earnes' determination to bring each successive edition thoroughly on a level with
the most advanced condition of contemporary medical  science, and  on no previous occasion has
tnis demanded a more patient and laborious effort than in rendering the present edition fully equal
to the wants of the student of the present day, and in no previous editions has the amount of "ew
matter introduced been so large.  While, therefore, the  reader who merely desire*  a vocabulary
explaining the terms in common  use can satisfy himself witl the smaller works, such as Hoblyn's,
the sludent and practi'ioner who wish a work to which they can at all times refer with unfailing
confidence 'or all which it is the province of such a book to supply, must still, as  heretofore, keep
the latest edi'ion of " Dunglison's Dictionary" within  reach.
   The mechanical execution of this edition will be found greatly superior to that  of  previous im-
pressions.  By enlarging the size of the volume to a royal octavo, and by the employment of a small
but dear type on extra fine paper, the additions have been incorporated without materially increas-
ing the buik of the volume, and the matter of two or three ordinary octavos has been compressed
into the space of one not unhandy for consultation and reference.
   A few notices of the previous editions are subjoined.
  This worn, the appearance of the fifteenth edition
of which it has become our duty and pleasure to
announce,is perhaps the most stupendous monument
of labor and erudition in medica! literature.  One
would hardly suppose after constant use of the pre-
ceding editions, where we have never failed to find
a sufficiently full explanation of ever) medical term,
that  in this edition "about six  thousand subjects
and terms have been added," with a careful revision
and correction of the entire work.  It is only neces-
sary to announce the advent of this edition to make
it occupy the place of the preceding one on the table
of every medical man, as it is withoutdoubt the best
and most comprehensive work of the kind which has
ever appeared.—Buffalo Med.Journ., Jan. 1858.
  The work is a  monument  of patient research,
skilful judgment, and vfest physical labor, that will
perpetuate the name of  the author  more effectually
than any possible  device of stone or metal.  Dr.
Dunglison deserves the thanks not only of the Ame-
rican profession, but of the whole medical world.—
North Am.  Medico-Chir. Review, Jan. 1858.
  A Medical Dictionary better adapted for the wants
of the profession than any other with which we are
acquainted, and  of a character which places it far
above comparison  and  competition.—Am  Journ.
Med. Sciences, Jan. 1858.
  We need only say, that the addition of 6,000 new
terms, with their accompanying definitions, may be
said  to constitute a new work, by itself.  We have
examined ttie Dictionary attentively, and are most
happy to pronounce it unrivalled of its kind.  The
erudition displayed, and the extraordinary industry
which must have been demanded, in its preparation
                                              wthor, and have furnished us with a volume indis-
                                              pensable at the present day, to all who would find
                                              themselves au niveau with the highest standards of
                                              nedical information.—Boston Medical and Surgical
                                              Journal, Dec. 31, 1857
                                                Good lexicons and encyclopedic works generally,
                                              ire the most labor-saving contrivances which lite-
                                              rary men enjoy; and the labor which is required to
                                              jroduce them in the perfect manner of this example
                                              s something appalling to contemplate. The author
                                              tells us in  nis prelace that be has added about six
                                              thousand terms and subjects to this edition, which,
                                              before, was considered universally as the best work
                                              of the kind in any language__Silliman's Journal.
                                              March, 1858.                                   '
                                                A complete and thorough exponent of medical
                                              terminology, without rival or possibility of rivalry.
                                              —Nashville Journ. of Med. and Surg., Jan. 1858.
                                                It is universally acknowledged, we believe, that
                                              this work is incomparably the best and most  com-
                                              plete  Medical  Lexicon in the English  language.
                                              Comment and commendation are unnecessary, as no
                                              one at the present da} thinks of purchasing any other
                                              Medical Dictionary than this.—St. Louis Med. and
                                              Surg. Journ., Jan  1858.
                                                It is the foundation stone of a good medical libra-
                                              ry, and should always be included in the first list of
                                              books purchased by the medical student.—Am. Med
                                              Monthly, Jan. 1858.
                                                It is scarcely necessary to remark that any medi-
                                              cal library wanting a copy of Dun?lison's Lexicon
                                              must be imperfect.—Cin. Lancet,  /an. 1858.
                                                The present edition we mav safely say has no  equal
and perfection, redound to the lasting credit of its in the world.—Peninsular Med. Journal  Jan. 1858. 
AND  SCIENTIFIC PUBLICATIONS.
13
                         DUNGLISON  (ROBLEY),  M.D.,
           Professor of Institutes of Medicine in the Jefferson Medical College, Philadelphia.

HUMAN  PHYSIOLOGY.   Eighth  edition.   Thoroughly revised  and exten-
  sively modified and enlarged, with five hundred and thirty-two illustrations.  In two large and
  handsomely printed octavo volumes, extra cloth, of about 1500 pages.  $7 00.

  In revising this work for its eighth appearance, the author has spared no labor to render it worthy
n continuance of the very great favor which  has been extended to it by the profession.   The whole
contents have been rearranged, and to a great extent remodelled; the investigations which of late
years have been so numerous and so important, have been carefully examined and incorporated,
and the work in every respect has been brought up to a level with the present state of the subject.
The object of the author has been to render  it a concise but comprehensive treatise, containing the
whole body of physiological science, to which the student and man of science can at all times refer
with the certainty of finding whatever they are in search of, fully presented in all its aspects ■ and
on no former edition has the author bestowed more labor to secure this result.
  We believe that it can truly be said, no more com-
plete repertory of facts upon the subject treated,
can anywhere be found.  The author has, moreover,
that enviable tact at description and that facility
and ease of expression which render him peculiarly
acceptable to the casual,  or the studious reader.
This facu'.ty, so requisite in  setting  forth  many
graver ant! less attractive subjects, lends additional
charms to one always fascinating.—Boston Med.
and Surg. Journal.

  The most  complete and  satisfactory system of
Physiology in the English  language.—Amer. Med.
Journal.
  The best  work of the kind in the English lan-
guage.—Silliman's Journal.
  The present edition the author has made a perfect
mirror of the science as it is at the present hour.
As a work upon physiology proper, the science of
the functions performed by the body, the student will
find it all he wishes.—Nashville Journ. of Med.
  That he has succeeded, most admirably succeeded
in his purpose, is apparent from  the appearance of
an eighth edition. It is now the great encyclopaedia
on the subject, and worthy of a place in every phy-
sician's library.—Western Lancet.
                                  BY THE SAME AUTHOR.

GENERAL  THERAPEUTICS  AND  MATERIA  MEDICA;  adapted  for  a
  Medical Text-book.  With Indexes of Remedies and of Diseases and their Remedies.  Sixth
  Edition, revised and improved.  With one hundred and ninety-three illustrations.  In two large
  and handsomely printed octavo vols., extra cloth, of about 1100 pages.  $6  50.

  In announcing a new edition of Dr. Dunglison's
General Therapeutics and Materia Medica, we have
no words of commendation to bestow upon a work
whose merits have been heretofore so often and so
justly extolled.  It must not be supposed, however,
that the present is  a mere reprint of the previous
edition: the character  of the  author for laborious
research, judicious  analysis, and clearness of ex-
pression, is fully sustained by the numerous  addi-
tions he has made to the work, and the  careful  re-
vision to which he has subjected the whole.—N. A.
Medico-Chir. Review, Jan. 1858.
  The work will, we have little doubt, be bought
and read by the majority of medical students: its
size, arrangement, and reliability recommend it to
all;  no  one, we venture to predict, will study it
without profit, and there are few to whom it will
not be in some measure useful as a work of refer-
ence.  The young practitioner, more especially, will
find the copious indexes appended to this edidon of
great assistance in the selection and  preparation of
suitable formulae.—Charleston Med. Journ. and Re-
view, Jan. 1858.
BY THE SAME AUTHOR
NEW REMEDIES, WITH FORMULAE FOR THEIR PREPARATION AND
  ADMINISTRATION.  Seventh edition, with extensive Additions.  In one very large  octavo
  volume, extra cloth, of 770 pages.  $4 00.
  One of the most useful of the author's works.—
Southern Medical and Surgical Journal.
  This elaborate  and  useful  volume  should be
found in every medical library, for as a book of re-
ference, for physicians, it is  unsurpassed by any
other work in existence, and the double index for
diseases and  for remedies, will be found greatly to
enhance its value.—New York Med. Gazette.
  The great learning of the author, and his remark-
able industry in pushing his researches into every
source whence information is derivable,have enabled
him to throw together an extensive mass of facts
and statements, accompanied by  full reference to
authorities; which  last feature renders  the work
practically valuable to investigators who desire to
examine the original papers.—The American Journal
of Pharmacy.
                            ELLIS (BENJAMIN), M.D.

THE  MEDICAL  FORMULARY: being a Collection of Prescriptions, derived
  from the writings and practice of many of the most eminent physicians of America and Europe.
  Together with the usual Dietetic Preparations and Antidotes for Poisons.  To which is added
  an Appendix, on the Endermic use of Medicines, and on the use of Ether and Chloroform.   The
  whole accompanied with a few brief Pharmaceutic and Medical Observations. Eleventh edition,
  carefully revised and much extended by Robert P. Thomas, M. D., Professor of Materia Me-
  dica in the Philadelphia College of Pharmacy.  In one  volume, 8vo., of about 350 pages. $3 00.
  (Just  Issued.)

  On no previous edition of this work has there been so complete and thorough a revision   The
extensive changes in the new United States  Pharmacopoeia have necessitated corresponding alter-
ations in the  Formulary, to conform to that national standard,  while the progress made in the
materia  medica and the arts of prescribing and dispensing  during the last ten years have been care-
fully noted and incorporated throughout.   It is therefore presented as not only worthy a continuance
of the favor so long enjoyed, but as more valuable than ever to the practitioner and pharmaceutist.
Those who possess previous editions  will  find the additional matter of sufficient importance to
warrant their adding the present to  their libraries. 
14                        HENRY C.  LEA'S  MEDICAL
                                 ERICHSEN (JOHN),
                     Professor of Surgery in University College, London, fte.

THE SCIENCE AND ART OF SURGERY;  being a Treatise on Surgioai
  Injuries, Diseases, and Operations. New and improved American, from the second enlarged
  and carefully revised London edition.   Illustrated with over four hundred engravings on wood.
  In  one large and handsome octavo volume, of one thousand closely printed pages, extra cloth,
  $6 00.
  The very distinguished favor with which this work has been received on both sides of the Atlan-
tic has stimulated the author to render it even more worthy of the position which it has so rapidly
attained  as a standard authority.   Every portion has been carefully  revised,  numerous  additions
have  been made, and the most watchful  care has been exercised to render it a complete  exponent
of the most advanced condition of surgical science.  In this manner the work has been enlarged by
about a hundred pages, while the series of engravings has been increased by more than a  hundred,
rendering it one of the most thoroughly illustrated volumes before the profession.   The additions of
the author having rendered unnecessary most of the notes of the former American editor,  but little
has been  added in this country; some  few notes and occasional illustrations have, however, been
introduced to elucidate American modes of practice.
  It is, in  our humble judgment, decidedly the best excellent  contribution to surgery, as probably th*
 book of the kind in the English language. Strange
 that just such books are notoftener produced by pub-
 lic teachers of surgery in this country and Great
 Britain.  Indeed, it is a matter of great astonishment.
 but no less true than astonishing, that of the many
 works on surgery republished in this country within
 the last fifteen  or twenty years as text-books for
 medical students, this is the only one that even ap-
 proximates to the fulfilment of the peculiar wants of
 youngmen justentennguponthe study ofthisbranch
 of the profession.— Western Jour .of Med. and Surgery.

  Its value is greatly enhanced by  a very copious
 well-arranged index.  We regard this as one of the
 most valuable contributions to modern surgery. To
one entering his novitiate of practice, we regard ii
the most serviceable guide which he can consult. He
will find a fulness of detailleadinghim throLgh every
Btep of the operation, and not deserting him until the
final issue of the case is decided.—Sethoscope.
  Embracing, as will be perceived, the whole surgi
cal domain, and each division of itself almost  com
plete and perfect,each chapterfull and explicit, eacl
subject faithfully exhibited, we can only express ou.
estimate of it in the aggregate.  We consider  it ar
 best single volume now extant on the subject, and
 with great pleasure we add it  to our text-books.—
 Nashville Journal of Medicine and Surgery.
  Prof. Erichsen's work, for its size, has not been
 surpassed; his nine hundred and eight pages, pro-
 fusely illustrated, are rich in physiological, patholo-
 gical, and  operative suggestions, doctrines, details,
 and processes; and will  prove a reliable resource
 foHnformation, both to physician and surgeon, in the
 hour of peril.—N. O. Med. and Surg. Journal.
  We may say, after a careful perusal of some of
 the chapters, and a more hasty examination of the
 remainder, that it must raise the character  of the
 author, and reflect great credit upon the college to
 which he is professor, and we can cordially recom-
 mend it  as a work of  reference  both to students
 and practitioners.—Med.  Times and Gazette.
  We do not hesitate to say that the volume  before
 us gives a veiy admirable practical view of the sci-
 ence and art of Surgery of the present day, and we
 have no doubt that it will be highly valued as a
 surgical guide as well  by the surgeon as  by the
 student  of surgery. — Edinburgh Med. and  Surg.
Journal.
FISKE  FUND PRIZE  ESSAYS. — THE EF-
  FECTS  OF  CLIMATE ON TUBERCULOUS
  DISEASE. By Edwin Lee, M. R. C. S , London,
  and THE INFLUENCE OF PREGNANCY ON
  THE DEVELOPMENT OF TUBERCLES  By
  Edward Warren, M. D., of Edenton, N. C. To-
  gether in one neat 8vo. volume, extra cloth. SI 00.
FRICK ON RENAL AFFECTIONS; their Diag.
  nosis and  Pathology.  With illustrations.  One
  volume, royal 12mo., extra cloth.  75 cents.
                       FERGUSSON  (WILLIAM), F.  R. S.,
                     Professor of Surgery  in King's College, London, &c.

A  SYSTEM  OF PRACTICAL SURGERY.   Fourth American, from the third
  and enlarged London edition.  In one large and beautifully printed octavo volume, of about 700
  pages, with 393 handsome illustrations, leather.  $4 CO.
                        FOWNES  (GEORGE), PH. D., 8cc.
A  MANUAL OF ELEMENTARY  CHEMISTRY;  Theoretical and Practical
  With one hundred *id ninety-seven illustrations.   Edited by Robert Bridges, M. D  In one
  large royal 12mo  volume,  of bOO pages, extra cloth, $2 00.
  The death of the author having placed the editorial care  of this work in the Dractised han/l« ««
Drs Bence Jones and A. W. Hoffman, everything has been done in its revision whic^experience
could suggest to keep it on a level with the rapid advance of chemical science   The additions
requisite to this purpose have necessitated an enlargement of the page, notwithstanding whinh th»
work has been increased by about fifty pages.  At the same  time ever?care  has bferT u2d £
maintain its distinctive character as a condensed manual for the student, divested of all unnecessary
detail or mere theoretical speculation.  The additions have, of course, been  mainlv in the Xnart
mentof Organic Chemistry, which has made such rapid progress wi'thhi'theTsYfew\Jr?bn
yet equal attention has been bestowed on the other branches of the subject—OhpmiJphS Q„J
Inorganic Chemistry-to present all investigations and discoveries of impori^ncTa^o^n ,,J
the reputation of the volume as a complete manual of the whole science,  admirahl'v a.lnniJl f™ thZ
learner   By the use of a small but exceedingly clear type the matter of a large 3£^comp^sed
within the convenient and portable limits of a moderate sized duodecimo  anil «t IL ™,,/i ,     •
affixed, it is offered as one of the cheapest volumes before the profession              y °W  P"Ce

                                              thT^LuoT^°/PT-  FoWneB has lonS been before
                                              Jltf.?£  k 'J" mcr,ts have been Fully apprec,.
                                              ated as the best text-book  on chemistry now  in
                                              existence.  We do not, of course, place it in a rank
  Dr. Fownes'excellent work has been universally
recognized everywhere in his own and this country,
as the best elementary treatise on chemistry in the
English tongue, and is very generally adopted, we
believe, as the standard text-book in all < ur colleges,
both literary and scientific— Charleston Med. Journ.
and Review
„„„„•„_ .„  .,-----,"■> «• vuuiac, piace ii in a rang
rZV^ l»  t^e works of Brande,'Graham, Turner,
Gregory, or Gmelm, but we say that, as a work
for students, it is preferable to any of them-L on
don Journal of Medicine. 
AND  SCIENTIFIC  PUBLICATIONS.                  IS
                             FLINT (AUSTIN), M.  D.,
   Professor of the Principles and Practice of Medicine in Bellevue Hosp. Med. College, New York.
                                    Now Ready, 1866.

THE  PRINCIPLES  AND PRACTICE OF  MEDICINE.   For  the use  of
  Practitioners and Students.   In one large and  handsome octavo volume of over 850  closely
  printed pages, leather, raised bands, $7; handsome extra  cloth, $6.
  The want has for some time been felt in this country of a volume which, within a moderate
compass, should give a clear and connected view of general and special pathology and therapeutics
in their most modern aspect.  Re rent researches have modified many opinions which were formerly
universally received on important points both of theory and practice, and these changes nave per-
haps as yet scarcely received the attention due to them in  the works accessible to the profession.
The author's reputation as a teacher is a guarantee  that the present volume will be fully up to the
most advanced state of the science of the day, while  his long and varied experience as a practi-
tioner will insure that in all practical details his work will be a sound and trustworthy guide.

                           by the same author.  (Preparing.)

PHYSICAL EXPLORATION AND DIAGNOSIS  OF DISEASES AFFECT-
  ING THE  RESPIRATORY ORGANS.  Second edition.  In one large and handsome octavo
  volume, extra cloth.
                                  BV THE SAME AUTHOR.

A PRACTICAL TREATISE  ON THE  DIAGNOSIS,  PATHOLOGY, AND
  TREATMENT OF DISEASES OF THE HEART.   In one neat octavo volume, of about
  500 pages, extra cloth.   $3 50.
  We do not know that Dr. Flint has written any-
thing which is not first rate; but this, his latest con-
tribution to medical literature, in our opinion, sur-
passes all the others. The work is most comprehen-
sive in it8 6cope, and most sound in the views it enun-
ciates.  The descriptions are clear and methodical;
the statements are substantiated by facts, and are
made with such simplicity and sincerity, that with-
out them  they would carry conviction. The style
is admirably clear, direct, and free from  dryness.
With Dr.  Walshe's excellent treatise before us, we
have no hesitation in saying that Dr. Flint's book is
the best work on the heart in the English language.
—Boston Med. and  Surg. Journal.
                          GRAHAM (THOMAS), F. R. S.

THE ELEMENTS  OF  INORGANIC  CHEMISTRY, including  the Applica-
  tions of the Science in the Arts.  New and much enlarged edition, by Henry Watts and Robert
  Bridges, M. D.  Complete in one \arge and handsome octavo volume, ol over 800 very large
  pages, with two hundred and thirty-two wood-cuts, extra cloth.  $5 50.
  **# Part II., completing the work from p. 431 to end, with Index, Title Matter, tec, may be
had separate, cloth backs and paper sides.  Price $3 00.
  From Prof. E. N. Horsford, Harvard College.   \ afford  to be  without this edition of Prof. Graham's
                                             Elements.—Silliman's Journal, March, 1858.
                                              From Prof. Wolcott Gibbs, N. Y. Free Academy
                                              The work  is an admirable one in all respects. an,d
                                             its republication here cannot fail to exert a positive
  It has, in its earlier and less perfect editions, been
familiar to me, and the excellence of its plan and
the clearness and completeness of its discussions,
have long been my admiration.
No reader of English works on this science can j influence upon theprogressofsciencein this country
                     GRIFFITH  (ROBERT E.), M. D., Sec.

A  UNIVERSAL FORMULARY, containing the methods of Preparing and Ad-
  ministering Officinal and other Medicines.  The whole adapted to Physicians and Pharmaceu.
  tists.  Second Edition, thoroughly revised, with numerous additions, by Robert P. Thomas,
  M. D., Professor of Materia Medica in the Philadelphia College of Pharmacy.  In one large and
  handsome octavo volume, extra cloth, of 650 pages, double columns.  $4 00.
  It was a work requiring much perseverance, and, vision and ample additions of  Dr  Thomas, and is
when published was looked upon as by far the best  now, we  believe, one of the mosi complete works
work of its kind that had issued from the American  of its kind in any language.  The additions amount
press.  Prof. Thomas has certainly "improved," as  toahoutseventy pages, and no effort has been spared
well as added to this Formulary, and has rendered it | to include in them all the recent improvements.  A
additionally deserving of the confidence of pharma-  work of this kind appears to us  indispensable to the
eeutists and physicians.—Am. Journal of Pharmacy,  physician, and there is none we can more cordially
  We are happy to announce a new and improved ' recommend—W.  Y. Journal of Medicine.
edition of this, one of the most valuable and useful
works that have emanated from an American pen.
It would do credit to any country, and will be found
                                               Pre-eminent among the best and most useful com-
                                             pilations of the present day will be found the work
of dailyVsefulness to practitioners' of medicinVf it is I before us, which can have been produced only at a
Setter adapted to their purposes than the dispensato-j r^rr^n8!.^!'?."?!^^.^!^^...^^^ ±
Ties.—Southern Med. and Surg. Journal.
  It is one of the most useful books a country practi-
tioner can possibly have.—Medical Chronicle.
  This is a work of.six hundred and fifty-one pages
embracing all on the subject of preparing and admi
nistering medicines that can be desired by the physi
cian and pharmaceutist.— Western Lancet.
  The amountof useful,every-day matter,for a prac
ticing physician,  is really immense.—Boston  Med
and Surg. Journal.
scription will suffice to show that we do not put too
high an estimate on this work   We are not cogni-
zant of the existence of a parallel work.  Its value
will be apparent 1o our readers from tne sketch of
its contents above given. We strongly recommend
it to all who are engaged either in practical medi-
cine, or moreexclusively with its literature.—Lond.
Med. Gazette.

  A very useful work, and a most complete compen-
dium on the subject of materia medica. We know
of no work in our language, or any other, so com-
This edition has been greatly improved by the  re- prehensive in all its details.—London Lancet. 
16                         HENRY" C. LEA'S MEDICAL
                           GROSS  (SAMUEL  D.),  M. D.,
             Professor of Surgery in the Jefferson Medical College of Philadelphia, &c.

                              Enlarged Edition.  Now Ready.

A  SYSTEM  OF  SURGERY:  Pathological, Diagnostic, Therapeutic, and Opera-
  tive.  Illustrated by over Thirteen Hundred Engravings.  Third edition, much enlarged and
  carefully revised.  In two large and beautifully printed royal octavo volumes, of '^200 pages;
  leather.  $15 00.  (Just Issued.)

  The  exhaustion within five years of two  large editions of so elaborate and comprehensive
 a work as  this is the best  evidence that  the author was  not mistaken in his estimate of the
 want which existed of a complete American System  of Surgery, presenting the science in all its
 necessary details and in all its branches.  That he has  succeeded in the attempt to supply this want
 is shown  not only by the rapid sale of the work, but also by the very favorable manner in which it
 has been received by the organs of the profession in this country and in Europe, and by the fact that
 a translation is now preparing in Holland—a mark of appreciation not often bestowed on any scien-
 tific work so extended in size.
  The author has not been insensible to the kindness thus bestowed upon his labors, and in revising
 the work for a third edition he has spared no pains to render it worthy of the favor with which it
 has been  received.  Every portion has been subjected  to close examination and revision ; any defi-
 ciencies apparent  have been supplied, and the results of recent progress in  the science and art of
 surgery have been everywhere introduced; while the series of illustrations has been still further
 enlarged, rendering it one  of the most thoroughly illustrated works ever laid before the profession.
 To accommodate these very extensive additions, the form of the work has been altered to a royal
 octavo, so that notwithstanding the increase in the matter and value of the book, its size wi I be found
 more convenient than before.   Every care has  been taken in the printing to render the typographical
 execution unexceptionable, and it is confidently expected to prove a work in  every way worthy ol
 a place in even the most limited library of the  practitioner or student.
  Has Dr. Gross satisfactorily fulfilled this object?
A careful perusal of his volumes enables us to give
an answer in the affirmative. Not only has he given
to the reader an elaborate and well-written account
of his own vast experience, but he has not failed to
embody in his pages the opinions and practice of
surgeons in this and other countries of Europe. The
result has been a work of such completeness, that it
has no superior in the systematic treatises on sur-
gery which have emanated from English or Conti-
nental authors.  It has been justly objected that
these have been far fromcomplete in many essentia]
particulars, many of them having  been  deficient in
some of the most important points which should
characterize such works  Some of them have been
elaborate—too elaborate—with respect to  certain
diseases, while they have merely glanced at, or
given an unsatisfactory account of, others  equally
important to the surgeon. Dr. Gross has avoided
this error, and has produced the most complete work
that has yet issued from the press on the science and
practice of surgery.  It is not, strictly  speaking, a
Dictionary of Surgery, but it gives to the reader all
the information that he may require for his treatment
 of surgical diseases.  Having said so much, it might
 appear superfluous to add another wjrd ; but it is
 only due to Dr. Gross to state that he has embraced
the opportunity of transferring to his pages a vast
 number of engravings from English and other au-
 thors, illustrative ol the pathology and treatment of
 Burgical diseases.  To these are added several nun
 dred original wood-cuts. The work altogether com-
 mends itself to the  attention of British surgeons,
 from whom it cannot fail to meet with extensive
 patronage.—London Lancet, Sept. 1, 1860.

   Of Dr. Gross's treatise on Surgery  we can say
 no more than that it is the most elaborate and com
 plete work on this branch of the healing art which
 has ever  been  published in any  country.  A sys-
 tematic work, it admits of no analytical  review;
 but, did  our space  permit, we should gladly give
 some extracts from it, to enable our readers to judge
 of the classical style of the author, and the exhaust-
 ing way in which each subject is treated.—Dublin
 Quarterly Journal of Med. Science.
   The work is  so superior to its predecessors in
 matter and extent, as well as in illustrations and
 style of publication, that we can honestly recom-
 mend  it  as the best work of the kind to be taken
 home by theyoung practitioner.—Am. Med. Journ.
   With pleasure we  record the completion of this
 long-anticipated work.  The  reputation which the
 author has for many years sustained, both as a sur-
 geon and as a writer, had prepared us  to expect a
 treatise of great excellence and originality; but we
confess we were by no means prepared for the work
which is before us—the most complete treatise upon
surgery ever published, either in this or any othtr
country, and we might, perhaps, safelv say,  the
most original.  There is no subject belonging pro-
perly to surgery which has tiot received from the
authoi a due share of attention.  Dr. Grots has sup-
plied a want in surgical literature which has long
been felt by practitioners; he has furnished us with
a complete practical  treatise upon surgery in all its
departments  As Anfiencms, we  are proud of the
achievement; as surgeons, we are most sincerely
thankful to him for his extraord nary labors in  our
behalf.—N. Y.  Review and Buffalo Med Journal.
  The great merit of the work may be stated as
follows.  It presents surgical science as it exists
at the latest date, with all its improvements;  and
it discusses every topic  in due  proportion.  No-
thing is omitted, nothing is in excess.—Chicago
Med Examiner, May, 1860.
  We cannot close this brief notice of Dr. Gross's
most valuable and excellent compendium of Sur-
gery without again  drawing attention lo it, as we
aid in our notice of his first edition, as an evidence
of the progress our American brethren are making
towards establishing a literature of their  own.—
Dublin Quarterly Journal, Feb. 1863.
   It has been  characterized by the representative
preBS and  by  individual surgeons of  the  highest
eminence,  both at home and abroad, as " the  best
systematic work on surgery ever published in the
English language;" and that the  profession at
large have given substantial proofs of their agree-
ment to ihis verdict, is sufficiently evident from the
fact that, translations into European languages have
 been called for, and that to shortly after its  first
 appearance, and at  a time most unfavorable to
 literary "enterprise," the Philadelphia puohshera
 have found it pay to issue a '« second edition, much
 enlarged and carefully revised."—American Med.
 Monthly, May, 1862
   We are much gratified to be able to announce a
 new edition of this  Cyclopaedia of Surgi ry.  Con-
 sidering the large size of the work and its expen-
 siveness, the extremely rapid sale and  exhaustion
 of an  entire edition, not only proves the  value of
 the work, and its adaptation to the wants of the
 profession, but it speaks well for the inielligence
 of American surgeons.—American Medical Times,
 May, 1862.                                    '

   A valuable and even necessary addition to every
 Burgical library .—Chicago Med. Journ., Dec. 1859.
   A system of  surgery which we think unrivalled
 in our language.—British American Journal.
                                    BY THE SAME AUTHOR..

A  PRACTICAL TREATISE  ON  FOREIGN BODIES IN  THE AIR-PAS-
  SAGES.  In one handsome octavo volume, extra cloth, with illustrations,  pp. 468.  $2 75. 
AND SCIENTIFIC  PU BL EC A TIONS.                  17
                            GROSS (SAMUEL D.), M. D.
             Professor of Surgery in the Jefferson Medical College of Philadelphia, Sec.

ELEMENTS  OF PATHOLOGICAL  ANATOMY.   Third  edition, thoroughly
  revised and greatly improved.  In one large and very handsome octavo volume, with about three
  hundred and fifty beautiful illustrations, of which a large number  are from original drawings,
  extra cloth.  $4 00.
  The very rapid advances in the Science of Pathological Anatomy during the last few years have
rendered essential a thorough modification of this work, with a view of making it a correct expo-
nent of the present state of the subject.   The very careful manner in which this task has been
executed, and the amount of alteration which it has undergone, have enabled the author to say that
" with the many changes and improvements now introduced, the work may be regarded almost as
a new treatise," while the efforts of the author have been seconded as regards  the  mechanical
execution of the volume, rendering it one of the handsomest productions of the American press.

                                   BY THE SAME AUTHOR.

A  PRACTICAL   TREATISE  ON  THE  DISEASES,   INJURIES,  AND
  MALFORMATIONS OF THE  URINARY BLADDER, THE PROSTATE GLAND, AND
  THE URETHRA.  Second Edition, revised and much enlarged,  with  one hundred and eighty-
  four illustrations.  In one large and very handsome octavo volume, of over nine hundred pages,
  extra cloth, $4 00.
  Philosophical in 'ts design, methodical  in  its ar-1 agree with us, that there is no work in the English
rangement, ample and sound in its practical details,' language which can make any just pretensions  to
it may in truth be said to leave scarcely anything to  be its equal.—N. Y.  Journal of Medicine
be desired on so important a subject.—Boston Med. I  A volume replete with truths and principles of the
and Surg  Journal.                              itmost value intheinvestigationof thesediseases.—
  Whoever will peruse the vast amount of valuable  American Medical Journal.
practical information it contains,  will,  we think, |
                             GRAY (HENRY),  F. R. S.,
                    Lecturer on Anatomy at St. George's Hospital, London, Sec.

ANATOMY, DESCRIPTIVE  AND  SURGICAL.    The Drawings  by  H.  V.
  Carter, M. D., late Demonstrator on Anatomy at St. George's Hospital; the Dissections jointly
  by  the Author and  Dr.  Carter.   Second American, from the second revised and improved
  London edition.   In one magnificent imperial octavo volume, of over 800 pages, with 388 large
  and elaborate engravings on  wood.  Price in extra cloth, $6 00; leather,  raised bands, $7 00.
  The speedy exhaustion of a large edition of this work is sufficient evidence that its plan and exe-
cution have been found to present superior practical advantages in facilitating the study of Anato-
my   In presenting it to the profession a second  time, the author has availed himself of the oppor-
tunity to supply any deficiencies which experience in its use had shown to exist, and to correct
any errors of detail, to which the first edition of  a scientific work on so extensive and complicated
a science is liable.   These improvements have resulted in some increase in the size of the volume,
while twenty-six new wood-cuts have been  added to  the beautiful series of illustrations which
form  so distinctive a feature of the work.   The American edition ha-, been passed through the press
under the supervision of a competent  professional man, who has taken every care to render it in
all respects accurate, and it is now presented, without any increase of price, as  fitted to maintain
and extend the popularity which it has everywhere acquired
  With little trouble, the busy  practitioner whose
knowledge of anatomy may have become obscured by
want of practice, may now resuscitate his former
anatomical lore, and be  ready for any emergency
It is to this class of individuals, and not to the stu-
dent alone, that this work will  ultimately tend to
be of most incalculable advantage, and we feel sat-
isfied that the library of the medical man will soon
be considered incomplete in which a  copy of this
work  does not exist.- Madras Quarterly Journal
of Med. Science, July, 1861.
  This edition is much improved and enlarged, and
contains several new illustrations by Dr. Westma-
cott.  The volume  is a  complete companion to the
dissecting-room, and saves the necessity of the stu
dent possessing a variety of" Manuals."—The Lon-
don Lancet, Feb. 9, 1861.
work of Mr. Gray to the attention of the medical
profession, feeling certain tnat it should be regarded
as one of the most valuable contributions ever made
to educational literature.—N. Y. Monthly Review.
Dec.1859.

  In this view, we regard the work of Mr. Gray as
far better adapted  to the wants of the profession,
md especially of the student, than any treatise on
matomy yet published in thiscountry. It is destined,
we believe, to supersede ill others, both as a manual
of dissections, and a standard of reference to  the
student  of general or  relative anatomy. — N. Y.
Journal of Medicine^ Nov. 1859.

  In our judgment, the mode of illustration adopted
in the present, volume cannot but present many ad-
vantages to the studentof anatomy.  To the zealous
  The work before us is one entitled to the highest I disciple of Vesalius, earnestly desirous of real im-
nraise  and we accordingly welcome  it as a valu- I provement, the book will  certainly be of immense
able addition  to medical literature.  Intermediate value; but, at the same time, we must also confess
in fulness of detail between the treatises of S.iar- that to those simply  desirous of " cramming" it
nev and of Wilson, its characteristic  merit lies in will be an undoubted godsend.  The peculiar value
the number and excellence of the engravings it of Mr. Gray's mode of illustration is nowhere more
contains   Most of  these are original, of  much | markedly evident than in the chapter on osteology,
larirer than ordinary  size, and admirably executed, and especially in  those portions which treat of the
The various parts are also lettered after the plan I bones of the head and of th^ir development.  The
odoDted in Holden's  Osteology.  It would be dim- | study of these parts is  thus made one of comparative
pnlt to over-estimate the advantages offered by this ease, if not of positive pleasure:  and thoBe bugbears
mode of pictorial illustration.   Bones, ligaments, | of the student, the temporal and sphenoid  bones, are
miiscles bloodvessels, and nerves are  each in turn shorn of half their terrors.  It is, in our estimation,
filiirerf and marked with their  appropriate names; an admirable and complete text-book for the student,
Jh ii a enabling the student to cemprehend, at a glance, | and a useful work of reference for the practitioner;
whnt would otherwise often be  ignored, or at any | its pictorial character forming a novel element, to
Jute acauired only by prolonged and irksome ap- which we have already sufficiently alluded.—Am.
plication  In conclusion, we heartily commend the Journ. Med. Set., July, 1859. 
IS                        HENRI'  C.  LEA'S  MEDICAL
GIBSON'S INSTITl TES AND PRACTICE OF
  SL'RGERV. Eighth edition, improved  and  al
  tered. With thirty-four plates  In two handsome
  octavo  volumes, containing  about 1,000 pages,
  Icither, raised bandi.  86 50
GARDNER'S MEDICAL CHEMISTRY, for  the
  use of Students and the Prof.-ssion.  In one royal
  l'2mo. vol., cloth, pp. 396, with wood-cuts.  81.
GLUGE'S ATLAS OF PATHOLOGICAL HIS-
  TOLOGY  Translated, with Notes and Addi-
  tions by Joskph Lbidt, M. D.  In one volume.
  very  large imperial quarto, extra cloth, with 320
  copper-plate figures, plain and eolored, 84 00.
HUGHES' INTRODUCTION  TO THE  PRAC-
  TICE  OF AUSCULTATION  AND  OTHER
  MODES OF PHYSICAL DIAGNOSIS IN DIS-
  EASKS  OF THELUNCiSAND HEART   Se-
  cond edition   1 vol. royal 12mo., ex. cloth, pp.
  304. SI  25.

HOLLAND'S  MEDICAL NOTES AND  RE-
  FLECTIONS.  From the third  London edition.
  In  one handsome octavo volume, extra cloth.
  83 50.
HORNER'S SPECIAL ANATOMY AND HIS.
  TOLOGY. Eighth edition.  ExtensivMy revised
  and modified.  In two large octavo volumes, ex-
  tra cloth, of more than 1000pages, with over 3'»»
  illustrations.  $6 00.
                           HILLIER (THOMAS),  M.D.,
 Physician to the Skin Department of University College Hospital;  Physician to the Hospital for Sick
                                     Children, &c. &c.
HANDBOOK  OF  SKIN  DISEASES, FOR  STUDENTS AND  PRACTI-
  TIONERS.   In one neat royal 12mo. volume, of about 300 pages, with two plates; extra cloth,
  price 82 25.   (Now Ready )
                              From the Author's Preface.
  '■ My object has been to furnish to students and practitioners a trustworthy, practical, and com-
pendious treatise, which shall comprise the greater part of what has long been known of cutaneous
diseases, and of what ha< been more recently brought to light by English, French, and German
dermatologists, as well as to embody the most important results of my own experience in reference
to these diseases "
  The author's position  both as a lecturer, wrter, and practitioner in this department of medicine,
is a guarantee of his ability to accomplish  his object in presenting a condensed and  convenient
manual, which shall comprise all that the general practitioner requires for  his guidance.
  A text book well adapted to the student, and the information contained in it shows the author to be au
niveau with the scientific medisine of the day—London Lancet, Feb. 25, 1865.

                        HAMILTON  (FRANK  H.),  M.  D.,
                    Professor of Surgery in the Long Island College Hospital.
A  PRACTICAL  TREATISE  ON  FRACTURES  AND   DISLOCATIONS.
  Second edition, revised and improved.   In one large and handsome octavo volume,  of over 750
  pages, with nearly 300 illustrations, extra cloth, $5 25.
  The early demand for a new edition of this work shows that it has  been successful in securing
the confidence of the profession as a standard authority for consultation and reference on  its import-
ant and difficult subject.  In iigain passing  it through the press, the author has taken the opportu-
nity to revise it carefully, and introduce whatever improvements have been suggested  by further
experience and observation  An additional  chapter on Gun-shot Fractures will be found to adapt
it still more  fully to the exigencies of the time.
  Among the many good workers at surgery of whom  affections.  One great and valuable feature in the
America may nowbpast rottheieast is Frank Hast- j work before us is the fact that it comprises all the
ings Hamilton; and the volume before us is (we say  improvements introduced  into the practice of both
it with a pang of wounded patriotism) the best and  English and American surgery, and though far from
handiest book on the subject in the Etglish  Ian- ' omitting mention of our continental neighbors, the
gunge.  It is in vain to attempt a review of it;  author by no means encourages the notion—but too
nearly as vain to seek for any sins, either of com- | prevalent in some  quarters—that nothing is good
mission or omission.  We have seen no work on  unless imported from France or Germany.   The
practical surgery which we would sooner recom-  latter half of  the work is devoted to the considera-
mend to our brother surgeons, especially those of j tion of the various dislocations and their appropri-
tl the services," or those whose practice lies in dis-  ate treatment, and its merit is fully equal to that of
tricts where a man has necessarily  to rely on his i the preceding portion__The London Lancet,May 5,
own unaided resources.  The practitioner will find j I860.
in t directions for nearly every possible accent, |   It is ernphaticany the book upon the subjects of
easily found and comprehended; and much pleasant  which u t^ats, and we cannot doubt  that  it will
H™!ftu™^                                        tobefor an indefinite period of time
tion of his asea.-Edinburgh Med. Journ Feb. 1661.  Wnen we saV) hoWever, that we believe it will at
  This is a valuable contribution to the surgery of  once take its place as the best book for consultation
most important affections,and is the morewelcome,  by the practitioner; and that it will form the most
inasmuch as at the present time we do not possess . complete, available, and reliable guide in emergen-
a single complete treatise on Fractures and Dislo- ; ciesof every nature connected with itssubjects; and
cations in the English language. It has remained for I also that the student of surgery may make it histext-
our American brother toproduce a complete treatise  book with entire confidence, and with pleasure also,
upon the subject, and bring together in a convenient  from its agreeable and easy style—we think our own
form those alterations and improvements that have; opinion may be gathered  as to its value.__Boston
been made from time to time in the treatment of these i Medical and Surgical Journal, March 1 1860.

                            HODGE (HUGH  L.), M. D.,
Professor of Midwifery and the Diseases of Women and Children in the University of Pennsylvania  Sec
ON  DISEASES  PECULIAR  TO  WOMEN,  including Displacements of'the
  Uterus.  With original  illustrations.   In one beautifully printed  octavo volume, of nearly 500
  pages, extra cloth. $3 75.
  This contribution towards the elucidation of the
pathology and treatment of some of the diseases
peculiar to women, cannot fail to meet with a favor
able reception from the medical profession.  The
character of the partieulnr maladies of which the
work before us treats; their frequency, variety,and
obscurity: the amount of malaise and even of actual
suffering by which they are invariably attended;
their obstinacy, the difficulty with which they are
overcome, and their disposition again and again to
recur—these, taken in connection with the entire
competency of the author to render a correct ac-
count of their nature, their causes, and their appro-
priate management—his ample experience, his ma-
tured judgment, and his perfect conscientiousness-
invest this publication with an interest and value to
which few of the medical treatises of a recent date
can lay a stronger, if, perchance, an equal claim —
Am. Journ. Med. Sciences, Jan. 1861.
The illustrations, which are all original, are drawn to a uniform scale of one-half the natural i 
AND  SCIENTIFIC  PUBLICATIONS.                 19
                           HODGE  (HUGH  L.), M. D.,
                  Late Professor of Midwifery, &c, in the University of Pennsylvania.

 PRINCIPLES AND  PRACTICE  OF OBSTETRICS.   In one large quarto
   volume of over 550 pages, with one hundred and fifty-eight figures on thirty-two beautifully exe-
   cuted lithographic plates, and numerous wood-cuts in the text.  $14 00.  (Just Issued.)
   This work, embodying the results of an extensive practice for more than forty years, cannot fail
 to prove of the utmost value to all who are engaged  in this department of medicine.  The author's
 position as one of the highest authorities on the subject in this country is well known, and the fruit
 of his ripe experience and  long observation, carefully matured and elaborated, must serve as an
 invaluable text-book for the student and an unfailing  counsel for the practitioner in the emergencies
 which so frequently arise in obstetric practice.
   The illustrations form a novel feature in  the work.  The  lithographic plates are all original,
 and to insure their absolute accuracy they have all been copied from photographs taken expressly
 for the purpose.   In ordinary obstetrical plates, the positions of the fetus are represented by dia-
 grams or sections of the patient, which are  of course purely imaginary, and their correctness is
 scarcely more than a matter of chance with the artist.   Their beauty as pictures is thereby increased
 without corresponding utility to the student, as in practice he must for the most part depend for his
 diagnosis upon the relative positions of the foetal skull and the pelvic bones of the mother.  It is,
 therefore, desirable that the points upon which he is in future to rely,  should form the basis of his
 instruction, and consequently in the preparation of these illustrations the skeleton has  alone been
 used, and the aid of photography invoked, by  which  a series of representations has been secured  of
 the strictest and most rigid accuracy.  It is easy to recognize the value thus added to the very full
 detai's on the subject of the Mechanism of Labour with which the work abounds
  It may be added that no pains or expense have been spared to render the mechanical execution of
 the volume worthy in every respect of the character and value of the teachings it contains.


                           HABERSHONIS.  O.),  M.D.,
   Assistant Physician to and Lecturer on Materia Medica and Therapeutics at Guy's Hospital, Sec.
PATHOLOGICAL  AND  PRACTICAL   OBSERVATIONS  ON  DISEASES
  OF THE ALIMENTARY CANAL, (ESOPHAGUS, STOMACH,  CAECUM, AND INTES-
  TINES.  With illustrations on wood.  In one  handsome octavo volume of 312 page*, extra
  cloth.  $2 50.
                         HOBLYN (RICHARD D.),  M. D.

A  DICTIONARY OF  THE  TERMS  USED  IN MEDICINE AND  THE
  COLLATERAL SCIENCES.  A new American edition.  Revised, with numerous Additions,
  by Isaac Hays, M. D., editor of the" American Journal of the Medical Sciences."  In one large
  royal 12mo. volume, cloth, of over 500 double columned pages.  $1 50
  To both practitioner and student, we recommend i use; embracing every department of medical science
this dictionary as being convenient in size, accurate
in definition, and sufficiently full and complete for
ordinary consultation.—Charleston Med. Journ.
  We know of no dictionary better arranged and
adapted. It is not encumbered with the obsolete terms
of a bygone age, but it contains all that are now in
down to the very latest date.—Western Lancet.
  Hoblyn's Dictionary has long been a favorite with
us.  It is the best book of definitions we have, and
ought always to be upon  the student's table.—
Southern Med. and Surg. Journal.
                        JONES  (T.  WHARTON),  F. R. S.,
          Professor of Ophthalmic Medicine and Surgery in University College, London, Sec.
THE  PRINCIPLES  AND  PRACTICE OF  OPHTHALMIC  MEDICINE
  AND SURGERY.  With one hundred  and seventeen illustrations.   Third and revised Ameri-
  can, with additions from the secono London edition.  In one handsome octavo volume, extra
  cloth, of 455 pages.  $3 25.
  Seven years having elapsed  since the appearance of the last edition of this  standard work, very
considerable additions have been found necessary to adapt it thoroughly to the advance of ophthal-
mic science.   The  introduction of the ophthalmoscope has resulted in adding  greatly to our know-
ledge of the pathology of the diseases of the eye, particularly of its more deeply seated tissues, and
corresponding improvements in medical treatment and operative procedures have been introduced.
All these matters the editor has endeavoured to add, bearing in mind the character of the volume as a
condensed and practical manual. To accommodate this unavoidable increase in the size of the work,
its form has been changed from a duodecimo to an  octavo, and it is presented as worthy a continu-
ance of the favour which has been bestowed on former editions.
  A  complete series  of " test-types" for examining^ the accommodating power of the eye, will be
found an important and useful  addition.
JONES (C. HANDFIELD), F. R. S., 8l EDWARD  H.  SIEVEKING,  M.D.,
                Assistant Physicians and Lecturers in St. Mary's Hospital, London.
A  MANUAL OF  PATHOLOGICAL  ANATOMY.   First American Edition,
  Revised.  With three hundred and ninety-seven handsome wood engravings.  In one large and
  beautiful octavo volume of nearly 750 pages, extra cloth.  $3 50.
  As a concise text-book, containing, in a condensed i obliged to glean from a great number of monographs.
form a complete outline of what  is known in the I and the field was so extensive that but few cultivated
doma'in of Pathological Anatomy, it is perhaps the \ it with any degree of success. As a simple work
best work in the English language. Its great merit : of reference, therefore, it is of great value to the
consists in its completeness and brevity, and in this ' student of pathological anatomy, and should be in
respect it supplies a great desideratum in our lite-  every physician's library.—Western Lancet.
rature. Heretofore the student of pathology was i 
20                       HENRY  C.  LEA'S MEDICAL
                   KIRKES (WILLIAM SENHOUSE),  M.D.,
               Demonstrator of Morbid Anatomy at St. Bartholomew's Hospital, Sec.

A  MANUAL  OF  PHYSIOLOGY.    A new  American,  from the  third  and
  improved London edition. With two hundred illustrations.  In  one large and handsome royal
  12ruo. volume, extra cloth,  pp. 586.  $2 25.
  This is a new and very much improved edition of l and its carefully cited authorities.  It is the  most
Dr. Kirkes'well-known Handbook of Physiology, convenientoftext-books. These gentlemen, Messrs.
It combines conciseness with completeness, and is, Kirkes and Paget, have the gift of telling us what
therefore, admirably adapted for consultation by the we want to know, without thinking  it necessary
busy practitioner.—Dublin Quarterly Journal
  One of the very best handbooks of Physiology wi
possess—presenting just such an outline of the sci-
ence as the student requiree during his attendance
upon a course of lectures, or for reference whilst
preparing for examination— Am. Medical Journal
  Its excellence is in its compactness, its clearness,
to tell us all they know.—Boston Med  and Surg.
Journal.

  For the student beginning this study, and the
practitioner who  has  but leisure to refresh his
memory, this book is invaluable, as it contains all
that  it is  important  to  know.—Charleston Med.
Journal
KNAPP'S TECHNOLOGY ; or.Chemistry applied
  to the Arts and to Manufactures. Edited by Dr.
  Ronalds, Dr. Richardson, and Prof. W.  R-
  Johnson. In two handsome 8vo. vols., extra cloth,
  with about 500 wood engravings. $6 00.
LAYCOCK'S  LECTURES  ON THE  PRINCI-
  PLES AND METHODS  OF  MEDICAL OB-
  SERVATION AND RESEARCH.  For the Use
  of Advanced Students and Junior Practitioners.
  In one royal 12mo. volume, extra cloth. Price SI.
                         LALLEMAND AND WILSON.
A   PRACTICAL  TREATISE  ON  THE  CAUSES,  SYMPTOMS,   AND
  TREATMENT OF SPERMATORRHOEA.  By M. Lallemand.  Translated and edited by
  Henry J  McDougall  Third American edition.  To which is added-----ON DISEASES
  OF THE  VESICULAE SEMINALES; and their associated organs.  With  special refer-
  ence to the Morbid Secretions of the Prostatic and  Urethral Mucous Membrane.  By Marris
  Wilson, M. D.   In one neat octavo volume, of about 400 pp., extra cloth. $2 75.

                          LA  ROCHE  (R.),  M. D.,  &c.
YELLOW FEVER, considered in its Historical, Pathological, Etiological,  and
  Therapeutical Relations. Including a Sketch of the Disease as  it has occurred in Philadelphia
  from 1699 to 1854, with an examination of the connections between it and the fevers known under
  the same name  in other parts of temperate as  well as in tropical regions.  In two large and
  handsome octavo volumes of nearly 1500 pages, extra cloth.  $7 00.
  We have not time at present, engaged as we are,
by day and by night, in the work of combating this
very disease, now prevailing in our city, to do more
than give this cursory notice of what we consider
as undoubtedly the most able and erudite medical
publication our country has yet produced  But in
view of the startling fact, that this, the most malig-
nant and unmanageable disease of modern times..
has for several years been prevailing in our country
to a greater extent than ever before; that it is no
longer confined to either large or small  cities, but
penetrates country villages, plantations, and farm-
houses; that it is treated with scarcely better  suc-
cess now than  thirty or forty years ago;  that there
is vast mischief done by ignorant pretenders to know-
ledge in regard to the disease, and in view of the pro-
bability that a  majority of southern physicians will
be called upon to treat the disease, we trust that this
able and comprehensive  treatise  will  be  very gene-
rally read in the south.—Memphis Med. Recorder.
BY THE SAME AUTHOR.
PNEUMONIA;  its Supposed Connection, Pathological and Etiological, with Au-
  tumnal Fever>, including an Inquiry into the  Existence and Morbid Agency of Malaria.   In one
  handsome octavo volume, extra cloth, of 500 pages.  $3 00.
                               LEHMANN  (C. G.)
PHYSIOLOGICAL  CHEMISTRY.    Translated from the  second  edition 'by
  George E. Day, M. D., F. R. S., tec, edited by R. E. Rogers, M. D., Professor of Chemistry
  in the Medical Department of the University  of Pennsylvania, with illustrations selected from
  Funke's Atlas of Physiological Chemistry, and an Appendix of plates.  Complete in two large
  and handsome octavo volumes, extra cloth, containing 1200 pages, with nearly two hundred illus-
  trations.  $6 00.
  The most important contribution as yet made to
Physiological Chemistry.—Am. Journal Med. Sci-
ences, Jan. 1856.
  The work of Lehmann stands unrivalled as the
most comprehensive book of reference and informa-
tion extant on every branch of the subject on which
it treats.—Edinburgh Journal of Medical Science. |
                                  BY the same author.

MANUAL  OF CHEMICAL  PHYSIOLOGY.    Translated from  the German,
  with Notes  and Additions, by J. Cheston Morris, M. D., with an Introductory Essay on Vital
  Force, by Professor Samuel Jackson, M. D., of the University of Pennsylvania.   With illus-
  trations on wood.  In one very handsome octavo volume, extra cloth, of 336 pages. $2 25.
                             LUDLOW (J.  L.l,  M. D.
A  MANUAL OF  EXAMINATIONS  upon  Anatomy, Physiology,  Surgery,
  Practice of Medicine, Obstetrics, Materia Medica, Chemistry, Pharmacy, and Therapeutics.  To
  which is added a Medical Formulary.  Third edition, thoroughly revised and greatly extended
  and enlarged.  With 370 illustrations.  In one  handsome royal 12mo. volume,  of 81b large
  pages, extra cloth, $3 2-3.
  We know of no better companion for the student I crammed into his head by the various professors to
during the hours spent in the lecture room, or to re- whom he is compelled to listen.—Western Lancet.
fresh, at a glance, his memory of the various topics | May, 1857. 
AND SCIENTIFIC  PUBLICATIONS.
21
                         LYONS (ROBERT  D.),  K.  C.  C,
                 Late Pathologist in-chief to the British Army in the Crimea, Sec.

A TREATISE  ON  FEVER; or, selections from a course of Lectures on Fever.
  Being part of a course of Theory and Practice of Medicine.   In one neat octavo volume, of 362
  pages, extra cloth;  82 25.  (JustIssued.)
■ vJ   V an admira»le work upon the most remark-
aoie and most important class of diseases to whicl
mankind  are liable.—Med. Journ. of N. Carolina
iviaj , tool.

  We have great pleasure in recommending Dr.
Lyons' work on Fever to the attention of the pro-
fession.  It is a work which cannot fail to enhance
the author's previous  well-earned reputation, as a
diligent, careful, and  accurate observer.—British
Med. Journal, March 2, 1861.
               MONTGOMERY (W. F.),  M. D.,  M. R. I. A.,  &c,
        Professor of Midwifery in the King and Queen's College of Physicians in Ireland, &c.

AN  EXPOSITION OF THE SIGNS  AND SYMPTOMS OF PREGNANCY.
  With some other Papers on Subjects connected with Midwifery.   From the second and enlarged
  English edition.  With two  exquisite colored  plates,  and numerous wood-cuts.  In one very
  handsome octavo volume, extra cloth, of nearly 600 pages.   $3 75.
  A book unusually rich in practical suggestions.—
Am  Journal Med. Sciences, Jan. 1857.
  These several subjects so interesting in them-
selves, and so important, every one of them, to the
most delicate and precious of social relations, con-
trolling often the honor and domestic  peace  of a
family, the legitimacy of offspring, or the life of its
parent, are all treated with an elegance of diction,
fulness of illustrations, acuteness and justice of rea-
soning, unparalleled in obstetrics, and unsurpassed in
medicine. The reader's interest can never flag, so
fresh, and vigorous, and classical is our author's
style; and one forgets, in ^he renewed charm of
wery pasre, that it, and every line, and every word
has been weighed and reweigned through years of
preparation ; that this is of all others the book ol
Obstetric Law, on each of its several topics; on all
points connected with pregnancy, to be everywhere
received as a manual of special  jurisprudence, at
once announcing fact, affording argument, establish-
ing precedent, and governing alike the juryman, ad-
vocate, and judge. — N. A. Med.-Chir. Review.
                           MEIGS(CHARLES D.), M.  D.,
          Lately Professor of Obstetrics, Sec. in the Jefferson Medical College, Philadelphia.

OBSTETRICS:  THE SCIENCE  AND THE  ART.   Fourth  edition, revised
  and improved.  With one hundred and twenty-nine illustrations. In one beautifully printed octavo
  volume, of seven hundred and thirty large pages, extra  cloth, $5 00.

                                From the Author's Preface.
  " [n  this edition I have endeavored to amend  the work by changes in its form ;  by careful cor-
rections of many expressions, and by a few omissions and some additions as to the text.
  "The Student will find that I have  recast the article on Placenta Praevia, which I was led to do
out of my desire to notice certain new modes of treatment which I regarded as not only  ill founded
as to the philosophy of our department, but dangerous to the people.
  " In  changing the firm of my work by dividing it into paragraphs  or sections, numbered from 1
to 959, I thought to pre>ent to the reader a common-pluce book of the whole volume  Such a table
of contents ought to  prove both convenient and usetul to a Student while attending public lectures."
  A work which has enjoyed so extensive  a reputation and has been received with such general
favor, requires only the assurance that the author has labored assiduously to embody in his new
edition whatever has been found necessary to render  it fully on  a level with the  most advanced
state of the subject.   Both as d text-book for the student and as a reliable work of reference  for
the practitioner, it is therefore to  be hoped  that the volume will be found worthy a continuance of
the confidence reposed in previous editions.

                                   BY THE SAME AUTHOR.

WOMAN: HER  DISEASES  AND THEIR  REMEDIES.   A Series of Lee
  tures to  his Class.  Fourth and Improved edition.  In one large and beautifully printed octave
  volume, extra cloth, of  over 700 pages.    $5 00.
  In other respects, in our estimation, too much can-
not be said in praise of this work.  It abounds with
beautiful passages, and for conciseness, for origin-
ality, and for all that is commendable in a work on
the diseases of females, it is not excelled, and pro-
bibly not equalled in the English language.  On the
whole, we know of no worK on the diseases of wo-
men which we can so cordially  commend  to the
student and practitioner as the one before us.—Ohio
Med. and Surg. Journal.
  The body of the book is worthy of attentive con-
sideration,  and is evidently the  production of a
clever, thoughtful, and sagacious physician.  Dr.
Meigs's letters on the diseases of the external or-
gan?, contain many interesting and rare cases, and
many instructive observations.  We take our leave
of Dr. Meigs, with a high opinion of his talents and
originality.—The British and Foreign Medico-Chi-
rurgical  Review.
  Every'chapter is replete with practical instruc-
tion, and  bears the impress of being the composition
of an acute and experienced mind.  There is a terse-
ness, and at the same time an  accuracy in his de-
■cription ol symptoms, and in the rules for diagnosis,
which cannot fail to recommend the volume to the
ittention of the reader.—Ranking's Abstract.

  It contains a vast amount of practical knowledge.
->y one who  has accurately observed and retained
the experience of many years.— Dub'.in Quarterly
Journal.
  Full of important matter, conveyed in a ready and
agreeable manner.—St.Louis Med. and Surg. Jour.

  There is an off-hand fervor, a glow, and a warm-
heartedness infecting the effort of Dr. Meigs, which
is entirely captivating, and which absolutely hur-
ries the reader through from beginning to end.  Be-
sides, the  book teems with solid instruction, and
it shows the very highest evidence of ability, viz.,
the clearness with  which the information js pre-
sented.   We  know of no better test of one's under-
standing a subject than the evidence of the power
jf lucidly explaining it.  The most elementary, as
.veil  as the obscurest subjects, under the pencil of
Prof. Meigs, are  isolated and made to stand out in
isuch bold relief, as to  produce distinct impressions
upon the mind and memory of the  reader. — The
Charleston Med. Journal, 
22                        HENRY  C.  LEA'S MEDICAL
                          MEIGS (CHARLES  D.)  M.  D.,
           Lately Professor of Obstetrics, Sec, in Jefferson Medical College, Philadelphia.

ON  THE   NATURE,  SIGNS,   AND  TREATMENT   OF   CHILDBED
  FEVER.  In a Series of Letters addressed to  the Students of his Class.  In one handsome
  octavo volume, extra cloth, of 365 pages.  $2  00.
  The instructive and interesting author of this
Work, whose previous labors have placed his coun-
trymen under deep and abiding obligations, again
challenges their admiration in the fresh and vigor-
ous, attractive and racy pages before us. It is a de-
lectable book. #  *  *  This treatise upon child-
bed fevers will have an extensive sale, being des-
tined, as it deserves, to find a place in the library
of every practitioner who scorns tolag in the rear.—
Nashville Journal of Medicine andSurgery.
                       MACLISE  (JOSEPH), SURGEON.

SURGICAL  ANATOMY.   Forming  one volume, very  large imperial  quarto
  With sixty-eight large and splendid Plates, drawn in the best style and beautifully colored. Con-
  taining one hundred and  ninety Figures, many of them the size of life.   Together with copious
  and explanatory letter-press.  Strongly and handsomely bound  in extra cloth, being one of the
  cheapest and best executed Surgical works as yet issued in this country.  $14 00.

   These plates will be found of  the  highest  practical value, either for  consulta-

tion  in emergencies or to  refresh  the recollections of the dissecting room.
  %* The size of this work prevents its transmission through the post-otfice as a whole, but those
who desire to have copies  forwarded by mail,  can receive them in five parts, done  up in stout
wrappers.  Price $12 00.
  One of the greatest artistic triumphs of the age |  A work which has  no parallel in point of accu-
in Surgical Anatomy.—British American Medical . racy and cheapness in  the English language.—N. Y.
Journal.
  No practitioner whose means will admit should
fail to possess it.—Ranking's Abstract.
  Too much  cannot be said in its praise;  indeed,
we have not language to do it justice.—Ohio Medi-
cal and Surgical Journal.
  The most accurately engraved and beautifully
colored plates we  have ever seen in an American
book—one of the best and cheapest surgical works
tver published.—Buffalo Medical Journal.
  It is very rare that so elegantly printed,  so well
illustrated, and so useful  a  work, is offered at so
moderate a price.—Charleston Medical Journal
  Its plates can boast a superiority which places
them almost beyond thereach of competition.—Medi-
%al Examiner.
  Country practitioners will  find these plates of im-
mense value—N. Y. Medical Gazette.
Journal of Medicine.
  We are extremely gratified to announce to ths
profession the completion of this truly magnificent
work, which, as a  whole,  certainly stands unri-
valled, both  for accuracy of drawing,  beauty  of
coloring, and all the requisite explanations of the
subject in  hand.—The  New Orleans Medical and
Surgical Journal.

  This is by far  the ablest work on Surgical Ana-
tomy  that  has come under our observation.  W«
know of no other work that would justify a stu-
dent, in any degree, for neglect of actual dissec-
tion.  In those  sudden emergencies that so often
arise, and which  require the instantaneous command
of minute anatomical knowledge, a work of this kind
keeps the details of the dissecting-room perpetually
fresh in thememory.—The Western Journal of Medi-
cine and Surgery.
                            MILLER (HENRY), M. D.,
     Professor of Obstetrics and Diseases of Women and Children in the University of Louisville.

PRINCIPLES  AND  PRACTICE OF OBSTETRICS, &c.;  including the Treat-
  ment of Chronic Inflammation of the  Cervix and Body of the  Uterus considered  as a frequent
  cause of Abortion.   With about one hundred illustrations on wood.   In one very handsome oc-
  tavo volume, of over 600 pages, extra cloth.  $3 75.
  We congratulate the author that the task is done.
We congratulate him that he has given to the medi-
cal public a work which will secure for  him a high
and permanent position among the standard autho
rities on the principles and practice of obstetrics.
Congratulations are not less due to the medical pro-
fession of this country, on the acquisition of a trea-
tise embodying the results of the studies, reflections,
and experience of Prof. Miller.—Buffalo Medical
Journal.
  In fact, this volume must take its place among the
standard systematic treatises on obstetrics; a posi-
tion to which its merits justly entitle it.__The Cin-
cinnati Lancet and Observer.
  A most respectable and  valuable addition to our
home medical literature,  and one reflecting credit
alike on the author and the institution to which he
is attached.  The student will find in this work a
most useful guide to his studies;  the country prac-
titioner, rusty in his reading, can obtain from its
pages a fair resume of the modern literature of the
science; and we hope to see this American produc-
tion generally consulted  by the  profession — V*
Med. Journal.                               '
                            MACKENZIE (W.),  M.D.,
                 Surgeon Oculist in Scotland in ordinary to Her Majesty, Sec.Scc.

A  PRACTICAL  TREATISE  ON DISEASES   AND  INJURIES OF  THE
  EYE.  To which is prefixed an Anatomical  Introduction explanatory of a Horizontal  Serti    I
  the Human Eyeball, by Thomas  Wharton  Jones, F. R. S.  From the Fourth Revised and°En
  laraed London Edition.  With Notes and Additions by Addinell Hewson  M  D  Sure    t
  Will- Hospital,tec. tec  In one very large and handsome  octavo volume, extra cloth' with urates
  and numerous wood-cuts  $6  50.                                             '      v
  The treatise of Dr. Mackenzie indisputably holds  I  We consider it the duty of every one who  has the
the firstplace, and forms, in respect of learning and  love of his profession and the welfare of his  patient
research, an Encyclopaedia unequalled in extent by  I at heart,  to make himself familiar with this the most
any other work of the kind,either English or foreign.  I complete work in the English language upon thedis-
—Dixon on Diseases of the Eye.                  \ eases of the eye__Med. Times and Gazette 
AND SCIENTIFIC  PUBLICATIONS.                 23
                          MILLER (JAMES), F.  R. S. E.,
                     Professor of Surgery in the University of Edinburgh, Sec.         '

PRINCIPLES OF SURGERY.   Fourth American, from  the  third and revised
  Edinburgh edition.  In one large and very beautiful volume, extra  cloth, of 700 pages, with
  two hundred and forty illustrations on wood.  $3 75.

                                 BY THE SAME AUTHOR.

THE  PRACTICE  OF  SURGERY.    Fourth  American from  the last  Edin-
  burgh edition.   Revised by the  American editor.  Illustrated by three hundred and sixtv-four
  engravings on wood.   In one large octavo volume, extra cloth, of nearly 700 pages.  $3  75.

 Jaj1- encotTUum of ours could add to  the popularity
of Miller's Surgery.  Its  reputation in this country
is unsurpassed by that of any other work, and, when
taken  in connection with the author's Principles of
Surgery, constitutes a whole, without  reference to
which no conscientious surgeon would be willing to
practice his art.— Soutkern Med. and Surg. Journal.
  It is seldom that two volumes have ever made so
profound an impression in  so short a time as the
" Principles" and the " Practice" of Surgery  by
Mr. Miller—or so richly merited the reputation they
have acquired.  The author is an  eminently sensi-
ble, practical, and well-informed man, who knows
exactly what he is talking about and exactly how to
talk it.—Kentucky Medical Recorder.
  By the almost unanimous  voice of the profession,
his works, both on the principles and practice of
surgery have been assigned the highest rank.  If we
were limited to but one work on surgery, that one
should be Miller's, as we regard it as superior to all
others.—St. Louis Med. and Surg. Journal.

  The author haB in this and his " Principles," pre-
sented to the profession one of the most complete and
reliable  systems of Surgery extant.  His style of
writing is original, impressive, and engaging, ener-
getic, concise, and lucid.  Few have the faculty of
condensing so much in small space, and at the same
time so persistently holding the attention. Whether
as a text-book for students or a book of reference
for practitioners, it cannot be too strongly recom-
mended.—Southern Journal of Med. and Physical
Sciences.
                           MORLAND  (W. WJ,  M. D.,
                       Fellow of the Massachusetts Medical Society, &c.
DISEASES  OF THE URINARY ORGANS; a Compendium of their Diagnosis,
  Pathology, and Treatment.  With illustrations
  about 600 pages, extra cloth.  $3 50.
  Taken as a whole, we can recommend Dr. Mor-
land's compendium as a very desirable addition to
the library of every medical  or  surgical  practi-
tioner ,-e.Bril  and For. Med.-Chir. Rev., April, 1859
  Every medical practitioner whose attention  has
been to  any extent attracted towards the class of
diseases to wtiich this treatise relates, must have
often and sorely experienced the want of some full,
yet concise recent compendium to which he could

                                   BY  THE SAME AUTHOR.

THE  MORBID  EFFECTS  OF THE  RETENTION  IN THE  BLOOD OF
  THE ELEMENTS OF  THE  URINARY SECRETION.  Being the Dissertation to which the
  Fiske Fund Prize was awarded, July 11, 1861.  In  one small octavo volume, 83 pages, extra
  cloth.  75 cents.
  In one large and handsome octavo volume, of


refer. This desideratum has been supplied by Dr.
Morland, and it has been ably done.  He has placed
before us  a  full, judicious, and reliable digest.
Each subject is  treated with sufficient minuteness,
yet in a succinct, narrational style, such as to render
the wonc one of great interest, and one which will
prove in the highest degree  useful  to the general
practitioner.—N. Y. Journ. of Medicine,
MAVNE'S  DISPENSATORY  AND   THERA-
  PEUTICAL REMEMBRANCER.  With every
  Practical Formula contained in the three British
j  Pharmacopoeias  Edited, with the addition of the
  Formulae of the U. S.  Pharmacopoeia, by R. E.
  Sriffith,M.D  1 12mo.vol.ex.cl.,300nD  75 c
MALGAIGNE'S OPERATIVE SURGERY, based
  on  Normal and Pathological Anatomy.  Trans-
  lated from the French by Frederick Brittan,
  A. B.,M.D. Withnumerousillustrationsonwood.
  In one handsome octavo volume, extra cloth, of
  nearlv six hundred pages.  ft2 f0
                NELIGAN  (J. MOORE), M. D.,  M. R. I. A., Sec.

ATLAS  OF  CUTANEOUS DISEASES.   In one beautiful quarto  volume, extra
  cloth, with splendid colored plates, presenting  nearly one hundred elaborate  representations of
  disease.  $5 50.
  This beautiful volume is intended as a complete and accurate representation o  all the varieties
of Diseases of the Skin.  While it can be consulted in conjunction with any work on Practice, it baa
esDecia? reference to the author's " Treatise on Diseases of the Skin," so favorably receved by the
P%fessln some years since.  The publishers feel justified in saying that few more beautifully exe-
cuted plates have ever been presented to the profession of this country
  Neligan's Atlas of Cutaneous Diseases supplies a
lone existent desideratum much felt by the largest
class of our profession.  It presents, in quarto size,
16 Dlates, each containing from 3 to 0 figures, and
forming in all a total of 90 distinct  representations
of the different species of skin affections, grouped
together in genera  or families. The illustrations
have been taken from nature, and have been copied
with such fidelity that they present a striking picture
r7flife" in which the reduced scale aptly serves to
                                   BY THE SAME AUTHOR.

A  PRACTICAL   TREATISE   ON   DISEASES OF  THE  SKIN.   Fourth
  American edition.  In one neat royal 12mo. volume, extra cloth, of 334 pages.  $1 50.
eive, at a coup d'aeil, the remarkable peculiarities
of each individual variety.  And while thus the dis-
ease is rendered more definable, there is yet no loss
of proportion incurred by the necessary concentra-
tion. Each figure is highly colored, and so truthful
has the artist been that the most fastid-ous observer
could not justly take exception to the correctness of
the execution of the  pictures under his scrutiny.—
Montreal Med. Chronicle. 
24
HENRY C. LEA'S MEDICAL
                              NEILL  (JOHN), M. D.,
                        Surgeon to the Pennsylvania Hospital, Sec.; and

                     FRANCIS GURNEY  SMITH, M. D.,
             Professor of Institutes of Medicine in the Pennsylvania Medical College.

AN ANALYTICAL  COMPENDIUM   OF  THE  VARIOUS   BRANCHES
  OF MEDICAL SCIENCE; for the Use and Examination of Students.  A new edition, revised
  and improved.  In  one very large and handsomely printed royal 12mo. volume, of about one
  thousand pages, with 374 wood-cut-, extra cloth, $4'00   Strongly bound in leather, with raised
  bands.   $4 7f>.
  This work is again presented as eminently worthy of  the favor wifh which it has hitherto
been received.  As a book for daily reference by the student  requiring a guide to his more elaborate
text-books, as a manual for preceptors desiring to stimulate their students by frequent and accurate
examination, or as a source from which the practitioners of older date may easily and cheaply acquire
a knowledge of the changes and improvement in professional science, its reputation is permanently
established.
  The beBt work of the kind with which we  are
acquainted.—Med. Examiner.
  Having made free use of this volume in our  ex-
aminations of  pupils, we can speak from experi-
ence in recommending it as an admirable compend
for students, and as especially useful to preceptors
who examine their pupils.  It will save the teacher
much labor by enabling him readily to recall all of
the  points upon which  his pupils should be  ex-
amined.  A work of this sort should be in the nands
of every one who takes pupils into his office with a
view of exnmining them ; and this is unquestionably
thebestof its class.—Transylvania Med. Journal

  In the rapid course of lectures, where work for
the students is heavy, and  review necessary for an
examination, a compend is not only valuable, but
it is almost a sine qua non   The one before us is,
in most of the divisions, the most unexceptionable
of all  books of the kind that  we know  of.  The
newest and  soundest doctrines and the latest im-
provements and discoveries are explicitly, though
concisely, laid before the student  There is a class
to whom We very sincerely commend this cheap book
as worth its weight in silver—that class is thegradu-
ates in medicine of more than ten years' standing,
who have not studied medicine since.  They will
perhaps find out from it that the science is not exactly
now what it was when they left it off.—The Stetho-
scope
                        PI RRIE (WILLIAM), F. R. 5. E.,
                      Professor of Surgery in the University of Aberdeen.

THE   PRINCIPLES  AND PRACTICE OF SURGERY.   Edited  by John
  Neill, M. D., Professor of Surgery in the Penna. Medical College, Surgeon tothe Pennsylvania
  Hospital, &c.  In one very handsome 8vo. volume, extra cloth, of 780 pages, with 316 illustrations.
  S3 75.
  We know of no other surgical work of a reason- i rately discussed the principles of surgery, and a
able size, wherein there is so much theory and prac-  safe and effectual practice predicated upon them.
tice, or where subjects are more soundly or clearly J Perhaps no work upon this subject heretofore issued
taught.—The Stethoscope.                      j is so full upon the science of the art of surgery.—
  Prof. Pirrie< in the work before us,  has elabo-1 Nashville Journal of Medicine and Surgery.
                            PARKER (LANGSTON),
                       Surgeon to the Queen's Hospital, Birmingham.

THE  MODERN TREATMENT  OF SYPHILITIC  DISEASES, BOTH  PRI-
  MARY AND SECONDARY;  comprising the Treatment of Constitutional and Confirmed Syphi-
  lis, by a safe and successful method.   With numerous Cases, Formulae, and Clinical Observa-
  tions. From the Third and entirely rewritten  London edition.   In one neat octavo volume.
  extra cloth, of 316 pages.   $2 50.
                        PEREIRA  (JONATHAN), M.D.

MATERIA  MEDICA AND THERAPEUTICS; being an  Abridgment of  the
  late Dr. Pereira's Elements of Materia MerJica, arranged in conformity with the briti-h Pharma-
  copoeia, and adapted to the use of Medical Practitioners, Chtmi^ts, and  Druggists, Medical and
  Pharmaceutical Students, &c.  By F. J. Farre, M. D., Senior Physician to St. Bartholomew's
  Hospital,  and London Editor of the British Pharmacopoeia;  assisted  by Robert Bentiey
  M.R C. S., Professor of Materia Medica and Botany  to the  Pharmaceutical Society of Great
  Britain; and by Robert Warington, F. R. S., Chemical Operator to the Society of Apothecaries
  With numerous additions and references lo the United States Pharmacopoeia, by Horatio C
  Wood, M. D., Professor of Botany in the University of Pennsylvania.  In one'large and hand-
  some octavo volume of about 900 pages, with numerous illustrations.  (Preparing.)
                         ROBERTS (WILLIAM) M. D.,
  Physician to the Manchester Royal InfirmHry, Lecturer on Medicine in the Manchester School of
                                     Medicine, &c.

A PRACTICAL  TREATISE  ON  URINARY  AND  RENAL  DISEASES,
  including Urinary Deposits.  Illustrated by numerous ca«es and engravings.  In one handsome
  octavo volume of over 500 page.--, extra cloth.  (Just Rtady.) 
AND SCIENTIFIC  PUBLICATIONS.                  25
                                PARRISH (EDWARD),
                Professor of Materia Medica in the Philadelphia College of Pharmacy.
A TREATISE  ON  PHARMACY.   Designed  as a  Text-book  for the  Student,
  and as a Guide for the Physician and Pharmaceutist.  With many Formulae and Prescriptions.
  Third-edition, greatly improved.  In one handsome octavo volume, of 850 pages, with several
  hundred Illustrations, extra cloth.  $5 00.  (Just Issued.)
  Though for some time out of print, ihe appearance of a new edition of this work has been de-
lated for the purpose of embodying in it the. results of the new U. S. Pharmacopoeia.  The pub-
lication of this latter has enabled the  author to  complete his revision in the most thorough manner.
Those who have been waiting for the work may therefore rely on obtaining a volume completely
on a level with the most advanced condition of pharmaceutical science
  The favor with which the work has thus far been received shows that the  author was not mis-
taken in his estimate of the want of a treatise which should serve  as a practical text-book fbr all
engaged in preparing and dispensing medicines.  Such a guide was indispensable not only to the
educated pharmaceutist, but also to that large class of practitioners  throughout the country who«
are obliged to compound their own prescriptions, and who during their collegiate course have no
opportunity of obtaining a  practical  familiarity with the  neces-ary processes and manipulations.
The rapid exhaustion of two large editions is evidence that the author has succeeded in thoroughly
carrying out his object.  Since the appearance of the last edition, much  has  been done to perfect
the science ;  the new Pharmacopoeia has introduced many changes to which the profession must
conform ; and the  author  has labored  assiduously to embody in his work all that physicians and
pharmaceutists can ask for in such a volume.  The new matter alone will thus be found  worth
more than the very moderate cost of the work to those who have been using the previous editions.
  All that we can say of it  is that to the practising
physician, and  especiall)  the country physician,
who is generally his own apothecary, there is hard-
ly any book that might not better be dispensed with
It is adtlie same time a dispensatory and a pharma-
cy.—Louisville  Review.
  A careful examination of this work enables us to
speak of it in the highest terms,  as  being the best
treatise on practical  pharmacy with which we are
acquainted, and an invaluable vade-mecum, not only
to the apothecary and to those practitioners who
are accustomed  to prepare tr eir own medicines, but
to every medical man and medical student.—Boston
Med. and Surg. Journal.
  This is altogether one of the most useful books
we have seen.  It is just what we have long felt to
be needed by apothecaries, students, and practition-
ers of medicine, most of whom in this country have
to put up their  own  prescriptions.  It bears, upon
every page, the impress of practical knowledge,
conveyed  in  a  plain  common sense manner, and
adapted to the comprehension of all who may redd
it__Southern Med. and Surg. Journal.
  That Edward Parrish, in writing a book upon
practical Pharmacy some few years ago—one emi-
nently  original  and  unique—did  the  medical and
pharmaceutical  professions  a great and valuable ser-
vice, no one, we think, who has had access to its
pages will deny; doubly welcome,then, is this new
edition, containing the added results of his recent
and rich experience as an  observer, teacher, and
practical operator in the pharmaceutical laboratory.
Tho excellent plan of the first is more thoroughly,
— Peninsular Med. Journal, Jan. I860.
  Of course, all apothecaries who have not already
a copy of the first edition will procure one of this j
it is, therefore, to physicians residing in the country
;ind in small towns, who cannot avail themselves of
the skill  of  an educated pharmaceutist, that  we
would esptcially commend  this work.   In  it they
will find all  that they  desire to know, and should
know, but very little of which they do really snow
in reference  to this important collateral branch of
their profession; for it is a well established fact,
that, in the education of physicians, while the sci-
ence of medicine  is generally well taught, very
little attention is paid to the art of preparing them
for use, and we know not how this defect can be so
well remedied as by procuring and consulting Dr.
Parrish's excellent work.—St. Louis Med. Journal.
Jan.1860.

   We know of no work on the subject which would
be more indispensable to the physician or  student
desiring information on the subjectof which it treats.
Willi Griffith's " Medicil Formulary" and this, the
practising physician would be supplied with nearly
or quite all the most useful  infor nation on the sub-
ject.—Charleston Med. Jour.and Review, Jan. 1860.
                               PEASLEE (E. R.),  M. D.,
          frofessor of Physiology and General Pathology in the New York Medical College.
HUMAN HISTOLOGY, in its  relations tu Anatomy, Physiology, and Pathology;
  for the use of Medical Students   With four hundred and thirty-four illustrations. In one hand-
  some octavo volume, extra cloth,  of over 600 pages   $3 75.
  It embraces a library upon  the topics discussed I   We would recommend it as containing a summary
within itself, and is just what the teacher and learner ! of all that is known of the important subjects which
"     ___   '      *   .   .      i     .     f n -    _■ i_ i____*._. ./ «11 »kn» In in rha <rruut timrlro nftSimnn
need.  We have not only the whole subject of His
tology, interesting in itself,ably and fully discussed,
but what is ot infinitely greater interest to the stu-
dent, because of greater practical value, are its re-
lations to Anatomy,  Physiology,  and  Pathology,
which are here fully and satisfactorily set forth.—
Nashville Journ. of Med and Surgery.

                           ROKITANSKY
     Curator of the Imperial Pathological Museum,
A   MANUAL  OK  PATHOLOGICAL
  bound in two, extra cloth, of about 1200 pages.
  king, C. H. Moore, and G. E. Day.  $7 50.
  The profession is too well acquainted with tne re-
nutation of Rokitansky's work to need our assur-
.«*<• that this is one of the most profound, thorough.
and valuable books ever  issued  from  the medical
»r«j«  It is sui generis, and has no standard of com-
narison  It is only necessary to announce that it is
Usued in a form as cheap as is compatible  with m
 it treats; of all that is in the great works of Simon
 and Lehmann, and the organic chemists in general.
 Master this one volume, and you know all that is
 known of the great fundamental principles of medi-
 cine, and ve have no hesitation in saying that it
 is an hoaor to the American medical profession.—
 St. Louis Mid. and Surg. Journal.

(CARL),   M.D.,
and Professor at the University of Vienna, &c
  ANATOMY.   Four  volumes,  octavo,
  Translated by W. E. Swaine, Edward Sievs-

 size and preservation, and  its sale follows as a
 matter of course.  No library can be called co n
 ilete without it.—Buffalo Med. Journal
   An attempt to give our readers any adequate idea
 if the vast amount of  instruction accumulated in
  hese volumes, would be  feeble unu  hopeless.__
 Western Lancet ,
ROYLE'S  .MATERIA  MEDICA   AND  THERAPEUTICS;  including  the
  v   oration- of the Pharmacopoeias of London, Edinburgh, Dublin, and of the United States.
  o/ohm»ovnew medicines-   Kdited by Joseph Carson, M. D.   With ninety-eight illustration*.
  l^oneTarg "octavo volume, extra cloth, of about 700 pages. S3 00. 
2«                       HENRY C.  LEA'S  MEDICAL
                           RIGBY (EDWARD),  M.D.,
                    Senior Physician to the General Lying-in Hospital, Sec.

A  SYTSTEM  OF  MIDWIFERY.  With Notes and  Additional Illustrations.
  Second American Edition.  One volume octavo, extra cloth, 422 pages.  $2 50.
BY THE SAME AUTHOR.
ON  THE  CONSTITUTIONAL  TREATMENT  OF  FEMALE DISEASES.
  In one neat royal 12mo. volume, extra cloth, of about 250 pages.   $1 00.
                    RAMSBOTHAM (FRANCIS  H.), M.D.

THE  PRINCIPLES AND  PRACTICE OF OBSTETRIC  MEDICINE AND
  SURGERY, in reference to the Process ol Parturition. A new and enlarged edition, thoroughly
  revised by the Author. With Additions by W. V. Keating,M. D., Professor of Obstetrics, &c, in
  the Jefferson Medical College, Philadelphia.  In one large and handsome imperial octavo volume,
  of 650 pages, strongly bound in leather, with raised bands; with sixty-four beautiful Plates, and
  numerous Wood-cuts in the text, containing in all nearly 200 large and beautiful figures.  $7 00.

                         From Prof. Hodge, of the University of Pa.
  To the American public, it is most valuable, from its intrinsic undoubted excellence, and as being
the best authorized exponent of British Midwifery.  Its circulation will, I trust, be extensive throughout
our country.
  It is unnecessary to say anything in regard to the
utility of this work. It is already appreciated in our
country for the value of the matter, the clearness of
its style, and the fulness of its illustrations.  To the
physician's library it is indispensable, while to the
student as a text-book, from which  to extract the
material for laying the foundation of an education on
obstetrical  science, it  has no superior.—Ohio Med
and Surg. Journal.
  The publishers have secured its success by the
truly elegant style in which they have brought it
out, excelling themselves in its production, espe-
cially in its plates. It is dedicated to ProflMeigs,
and has the emphatic endorsement of Prof. Hodge,
as the best exponent of British Midwifery.  We
km.w of no text-book which deserves in all respects
to be more highly recommended to students, and we
could wish to see it in the hanusof every practitioner,
for they will find it invaluable for reference.—Med.
Gazette.
                               RICORD (P.), M. D.

LETTERS  ON SYPHILIS.   Translated by W. P. Lattimorb, M. D   In one
  neat octavo volume, of 270 pages, extra cloth.  $2 00.
   SMITH (HENRY  H.),  M. D.,  AND  HORN ER (Wl LLI AM  E.), M.D.

AN  ANATOMICAL ATLAS, illustrative of the  Structure of the Human Body.
  In  one  volume, large imperial  octavo, extra cloth, with about six hundred and fifty beautiful
  figures. $4 50.
  The plan of this Atlas, which renders it so pe-
culiarly convenient for the student, and its superb
artistical execution, have been already pointed out.
We must congratulate the student upon the comple-
tion of this Atlas, as it is the most convenient work
of the kind that hasyet appeared ; and we must add,
the very beautiful manner in which it is " got up''
is so creditable to the  country as to be flattering
to our national pride.—American Medical Journal.
                  SMITH  (EDWARD),  M.D., LL.D., F.R.S.
    Assistant Physician to the Hospital for Consumption and Diseases of the Chest, Brompton, Sec.

CONSUMPTION;  ITS  EARLY  AND  REMEDIABLE  STAGES.  In one
  neat octavo volume of 254 pages, extra cloth.  $2 25.  (Just Issued.)
  One-half of Dr. Smith's work  is devoted to the  than to drugs in the treatment of the disease  In
treatment of Tuberculosis. We find in this portion  , taking leave of the work, we would express the
of the work no occasion to join issue with the au-  j hope that the author will furnish occasions for the
thor; but, on the contrary, much which we would  j renewal of our intercourse as a reader, if notasa
commend to the reader's attention.  Dr. Smith at-  leviewer.—Am. Med. Journal, Jan. 1863.
tacnes far greater importance to hygienic measures  I
SHARPEY (WILLIAM), M.D.,  JONES QUAIN, M.D., AND
                 RICHARD  QUAIN,  F. R. S., Sec.
SOLLY ON THE HUMAN BRAIN; itsStructure,
  Physiology, and Diseases.  From the Second and
  much emaiged London edition!  In one octavu
  volume, extra cloth, of 500 pages, with 120 wood-
  cuts. *a r-o
S«tEY'8 OPERATIVE SURGERY . In one very
  handsome octavo volume, extra cloth, of over 650
  pages, with about one hundred Wood-cuts  »a''5
SIMON-f UKISKRai. PATHOLOGY, as conduc-
  ive to the  hstabl.shment of Rational Prtaciplei
  for the prevention an. Cure of  Disease  In one
  octavo volume, extra cloth, of 212 page«.  SI as. 
AND SCIENTIFIC  PUBLICATIONS.                   27
                             STILLE  (ALFRED),  M. D.,
          Professor of the Theory and Practice of Medicine in the University of Pennsylvania.
THERAPEUTICS AND  MATERIA  MEDICA;  a Systematic Treatise on the
  Action and Uses of Medicinal Agents, including their Description and History.  Second Edition,
  revised and enlarged.  In two large and handsome octavo volumes, extra cloth.  $10 00.   (Just
  Issued.)
  This work is designed especially for the student and practitioner of medicine, and treats the various
articles of the Materia Medica from the point of view of the bedside, and not of the shop or of the
lecture-room.   While thus endeavoring to give all practical information likely to be useful  with
respect to the employment of special remedies in special affections, and  the results to be anticipated
from their administration, a copious Index of Diseases and their Remedies renders the work emi-
nently fitted for reference by showing at a glance ihe different means which have been employed,
and enabling the practitioner to extend his resources in difficult cases with all that the experience
of the profession has suggested.
  The speedy demand for another edition of this work shows that it has acceptably filled an acknow-
ledged want   No t xertion of the am hor has been wanting to render it worthy a continuance of the
favor with which  it has been  received, while an alteration in the typographical  arrangement has
accommodated the additions without increasing unduly the size of the volumes.
                                               tioncd, Stille. His great work oj> " Materia Medi-
                                               ca and Therapeutics," published last year, in two
                                               octavo volumes,  of some sixteen hundred  pages,
                                               while it embodies the results of the labor of others
                                               up to the time of publication, is enriched with a
                                               great amount of original observation and research.
                                               We would draw attention, by the way, to the very
                                               convenient mode in which the Index is arranged in
                                               this work. There is first an '' Index of Remedies;'
                                               next an " Index of  Diseases and their Remedies."
                                               Such an arrangement of the Indices, in our opinion,
                                               greatly enhances the practical value of books of this
                                               kind.  In tedious, obstinate cases of disease, where
                                               we have to try one remedy after another until our
                                               stock is pretty nearly exhausted, and we are almost
  Rarely, indeed, have we had submitted to us a
work on medicine so ponderoub in its dimensions
as that now before us, and yet so fascinating in its
contents.  It  is,  therefore, with a peculiar gratifi-
cation that we recognize in Dr. Stille  the posses-
sion of many of those more distinguished qualifica-
tions which entitle him to approbation, and which
justify him in coming before his medical brethren
as an  instructor.  A comprehensive knowledge,
tested by a sound and penetrating judgment, joined
to a love of progress —which a discriminating spirit
of inquiry has tempered so as toacce.pt nothing new
because it is new, and abandon nothing old because
it is old, but which estimates either accori ing to its
relations to a just logic atnd experience—manifests
itself everywhere, and gives to the guidance of the | driven to our wit's end, such an index as the second
author all 'he assurunce of safety which ihe diffi-
culties of his subject can allow.  In conclusion, we
earnestly advise our readers to ascertain for them-
selves, by a study of Dr Stille's volumes, the great
value and interest of the stores of Knowledge they
present.  We have pleasure in referring rather to
the ample treasury of undoubted truths, the real and
assured conquest  of medicine, accumulated by Dr.
Stille in his pages; and commend the sum of his la-
bors to the attention of our readers, as alike honor-
of the two just mentioned, is precisely what we
want.—London Med. Timesand Gazette, April, 1861.
  We think this work will do much to obviate the
reluctance to a thorough investigationof this branch
of scientific study, for in the wide range of medical
literature treasured in the English tongue, we shall
hardly find a work written in u style more clear and
simple,conveying forcibly the facts taught, and yet
free from turgidity and redundancy.  There isa fas-
cination in its pages that will insure to it a wide
able to our science, and  creditable to the zeal, the j popularity and attentive perusal, and a detrree of
candor, and the judgment of him who has garnered j UBefuilless not often attained through the influence
the whole so carefully.—Edinburgh Med. Journal. | 0l a 8i[lgie WOrk.
  The most recent authority is the one last men- i

                               SIMPSON  (J.  Y.),  M. D.,
                  Professor of Midwiiery, Sec, in the University of Edinburgh,&c.
CLINICAL  LECTURES  ON  THE  DISEASES OF  WOMEN.    With  nu-
  meious illustrations.   In one handsome octavo  volume, of over  500 pages,  extra cloth, $4 00.
  The principal topics embraced in the Lectures are Vesico-Vaginal Fistula, Cancer of the Uterus,
Treatment of Care noma by Caustics, Dysmenorrhoea, Amenorrhoea, Closures, Contractions, tec,
of the Vagina, Vulvitis,  Causes of Death after Surgical  Operations, Surgical  Fever, Phlegmasia
Dolens Coccyodinia, Pelvic Cellulitis,  Pelvic Heematoma, Spurious  Pregnancy, Ovarian Dropsy,
Ovariotomy, Cranioclasm, Diseases of the Fallopian  Tubes, Puerperal Mania,  Sub-Involution and
Super-Involution ol the Uterus, &c. &o.
  As a series of monographs on these  important topics—many of which receive little attention
in the ordinary text-books—elucidated with the extensive experience and readiness of resource lor
which Professor Simpson is so distinguished, there are tew practitioners  who  will not find in its
pages matter of the utmost importance  in the treatment of obscure and difficult cases.

                               SALTER  (H.  H.),  M.  D.
ASTHMA;  its Pathology, Causes, Consequences,  and Treatment.    In one vol.
  8vo., extra cloth  (Just Issued.)   f^ 50.
  The portion of Dr. Salter's worK which is devoted
to treatment, is of great practical inierescand value.
It would be necessary to  loilow him step by step
in his remarks, not only on the medicinal, but also
on the dietetic and hygienic treatment of the disease,
in order to convey a just not ion ottne practical value
of this part of his work.  This our space forbius,
and this we shall little regret, if, by our silence,
we should induce our readers to possess themselves
of the book itself;  ab'iok which, without uoubt, de-
serves to be ranked am >ng the most valuable of re-
cent contributions to the medical literature of this
country.— Kanking's Abstract, Jan , 1961.
                                SLADE  iD. D.),  M. D.
DIPHTHERIA:  its Nature and Treatment, with an account of  the History of
  its Prevalence  in various countries
  volume, extra cloth.   $125.   (Jus
  Tne  original  essay of Dr. Slade, to which  the
 r.tkJ Fund  prize tor 1660 was awarded, appeared
or finally in Uus.lournol  In the edition betore us
U e^essav has ueen revi-ed with ev.centcare, w.ule
such addV.ons have b.en marie to  ,t as were sug
gested  by tue author's substqueut experience and
       Second and revised edition.  In  one neat royal 12mo.
(Just Issued.)
               observation In its present form, the work furnishes
               to the student and young practitioner a very faithful
               and useful exposition of tin- principal facts. Inat are
               now known in respect to 'he naiure of diphtheria,
               its causes and treatment.—Am Journ Med Sciences,
               Jan. Ib65. 
28
HENRY C. LEA'S MEDICAL
                            SARGENT  (F.  W.),  M. D.
ON BANDAGING  AND  OTHER  OPERATIONS OF  MINOR SURGERY.
  New edition, with an additional chapter on Military Surgery.  One handsome royal 12mo. vol.)
  of nearly 400 pages, with 184 wood cuts.  Extra cloth, $1 75.
  The value of this work as a handy and convenient manual for surgeons engaged in active duty, has
induced the publishers to render it more complete for those purposes by the addition of a chapter
on gun-shot wounds and other matters peculiar  to military surgery.   In its present form, there-
fore, it will be found a very cheap and convenient vade-mecum for consultation  and  reference  in
the daily  exigencies of military as well as civil practice.
                                              The instruction given upon the subject of Ban-
                                            daging, is alone of great value, and while the author
                                            modestly proposes to instruct the students of medi-
                                            cine, and the younger physicians, we will say that
                                            experienced physicians will  obtain many exceed-
                                            ingly valuable  suggestions by its perusal.  It will
                                            be found one of the most satisfactory manuals for re-
                                            ference in the field, orhospital yet published; thor-
                                            oughly adapted to the wants of Military surgeons,
                                            and at the same time equally useful for ready and
                                            convenient  reference  by  surgeons everywhere.—
                                            Buffalo Med. and Surg. Journal, June,  1862.
  We consider that no better book could be placed
in thehiir.usof an hospital dresser, or the young sur-
geon, v hose education in this respect has not been
perfected  Wt most cordially commend this volume
as one which the medical student should most close
l> study, to perfect himstlf in these minor surgical
operations in which neatress and dexterity are so
much required, and on which a great portion of his
reputation as a future surgeon must evidently rest.
Aid to ihe surgeon in practice it  must  prove itself
a valuable volume, as instructive on many points
which he  may have forgotten.—British American
Journal,Ms.y, 1862.
                          SMITH (W.  TYLER), M. D.,
                      Physician Accoucheur to St. Mary's Hospital, Sec.
ON  PARTURITION,  AND  THE  PRINCIPLES  AND  PRACTICE  OF
  OBSTETRICS.  In one royal 12mo. volume, extra cloth, of 400 pages.  $1  50.
                                 BY THIS SAME AUTHOR.
A PRACTICAL  TREATISE  ON  THE  PATHOLOGY AND TREATMENT
  OF  LEUCORRHCEA.  With numerous illustrations.   In  one very handsome octavo volume,
  extra cloth, of about 250 pages.  $2 00

                            TANNER  (T.  H.),   M. D.,
                         Physician to the Hospital for Women, &c.

A MANUAL OF CLINICAL  MEDICINE AND  PHYSICAL DIAGNOSIS
To  which  is added  The Code of Ethics of the American Medical  Association.
American Edition.  In one neat volume, small 12mo., extra cloth.   (Preparirg.)
Third
                   TAYLOR (ALFRED  S.),  M. D., F. R. S.,
               Lecturer on Medical Jurisprudence and Chemistry in Guy's Hospital.

MEDICAL JURISPRUDENCE.   Fifth American, from the seventh  improved
  an' enlaiged London edition.  With Notes and References to American Decisions, by Edward
  Hartshorne,M. D.  In one large 8vo. volume, extra cloth, of over 700 pages.  $4 00.
  Tins standard work having had the advantage of two revisions at the hands of the author since
the appearance of the last American edition, will be found thoroughly revised and brought up com-
pletel>  to the present stale ol the science.  As a work of  authority, it must therefore  maintain its
position, both as a text-book for the student, and a compendious treatise to which the  practitioner
can at all times refer in cases of doubt or difficulty.
                                            American and British legal medicine.  It should be
                                            in the possession of every physician, as the subject
                                            is one of great and increasing  importance to the
                                            public as well as to the profession.—St  Louts Med
                                            and Surg. Journal.
  No work  upon the subject can be put into the
bands of students either of law or medicine which
will engage them more closely or profitably; and
none could  be offered to the busy practitioner ol
either calling, for the purpose of casual  or hasty
reference, that would be more likely to afford the aid
desired.  We thereforerecommend it as the best and
safest  manual for daily use.—American Journal oj
Medical Sciences
  ll is not excess of praise  to say that the volume
before us is the very best treatise extant on Medica]
Jurisprudence  In  saying this, we do not wish U
be understood as detracting from  the  merits of tin
excellent works of Beck, Ryan, Traill, (iuy, ant'
others; but  in interest and value we think it  must
be conceded that Taylor is superior to anything thai
has preceded it.—IV. W. Medical and Surg. Journal
  It is at once comprehensive and eminently prac-
tical, and by universal consent ttanus at the head of
                                BY THE SAME AUTHOR.

ON POISONS, IN RELATION TO  MEDICAL  JURISPRUDENCE  AND
  MEDICINE.  Second American, from a second and revised  London edition   In nn» I
  octavo volume, ol  755 pages, extra cloth.   $5 00.                                 "ue lar&e

  Mr. Taylor's position as the leading medical jurist of England, has conferred on him extraordi
nary advantages in acquiring experience on these subjects,  nearly all cases of moment beinir"
relerr<?d to him for  examination, as an expert whose testimony is generally accepted as final
The results of his labors, therefore, as gathered together in this volume, carefully weighed  and
sated, and presented in the clear and intelligible style for which he is noted, may be received
as an  acknowledged authority, and as a guide to be followed with implicit confidence.
                         BY THE SAME AUTHOR AND WM  BRANDS.

CHEMISTRY.   In one volume «vo.   See "Bbande," p.  6.
  This work of Dr. Taylor's is generally acknow-
ledged to be one of the ablest extant on the subject
of medical jurisprudence. It is certainly one of the
most attractive oo iks that we have met with •  sur>-
plymg so much both to  interest and instruct  that
we do not hesitate to affirm that after havine'onee
commenced its perusal, few could be prevailed unon
to desist before completing it.  In  the last London
edition  all  the newly  observed and accurately re
corded facts have been  insetted,  including much
that is recent of Chemical, Microscopical, and Pa
thological research, besid, s papers  on numerous 
AND  SCIENTIFIC PUBLICATIONS                  29
                TODD (ROBERT  BENTLEY), M. O., F. R. S.,
                    Professor of Physiology in King's College, London; and
                        WILLIAM BOWMAN, F. R. S.,
                     Demonstrator of Anatomy in King's College, London.

THE PHYSIOLOGICAL ANATOMY AND  PHYSIOLOGY OF MAN.  With
  about three hundred large  and beautiful illustrations on wood. Complete in one large octavo
  volume, of 950 pages, extra cloth.  Price $4 75.
  Itis more concise than Carpenter's Principles, and
more modern than theaccesBibleedition of Mailer's
Elements; its details are brief, but sufficierit
descriptions vivid; its illustrations exact and copi-
ous ;  and its language  terse  and perspicuous.—
Charleston Med. Journal.
  A magnificent contribution to British medicine,
and the American physician who shall fail to peruse
it, wih have failed to read one of the most instruc-
tive books of the nineteenth century.—JV. O. Med.
%nd Surg. Journal.
                      TODD (R.  B.)  M. D., F. R. S., &c.
CLINICAL LECTURES  ON  CERTAIN  DISEASES  OF THE URINARY
  ORGANS AND ON  DROPSIES.  In one octavo volume, 284 pages, extra cloth.  $2 50
                                 BY THE SAME AUTHOR.
CLINICAL LECTURES  ON CERTAIN  ACUTE DISEASES.   In  one neat
  octavo volume, of 320 pages, extra clotn.  $2 50.
                         TOYNBEE  (JOSEPH),  F.R.S.,
               Aural Surgeon to, and Lecturer on Surgery at, St. Mary's Hospital.

A PRACTICAL  TREATISE  ON  DISEASES  OF  THE  EAR;  their Diag-
  nosis, Pathology, and Treatment.  Illustrated with one hundred engravings on wood.  In  one
  very handsome octavo volume, extra cloth, $4 00.
  The work is a model of its kind, and every page  ; Surgery, it is without a rivsl in our language or any
and paragraph oi it are worthy of the most thorough  other.—Charleston Med Journ and Rev , Sept I860.
study.  Considered all in all-as an original work,  |  The work of vlr< Toynbet Ig undoubtedly, upon
well written, philosophically elaborated, and happi-  -■
ly illustrated with cases and drawings—it is bv far
the ablest monograph that has ever appeared on the
anatomy and diseases of the ear, and one of the most
valuable contributions to theart and science of sur-
gery in the nineteenth century.—JV. Amer. Medico-
Chirurg. Review, Sept. 1860.
  We are speaking within the limits of modest ac-
knowledgment,  and with a sincere and unbiassed
judgment, when we affirm that as a treatise on Aural
the whole the most valuable proJuc.ion of tne kind
in any language.  The author has long oeen known
by his numerous monographs upon subjects  con-
nected with diseases of the ear, and is now regarded
as  the nighest authority on most points in his de-
partment of science. Mr Toynbee's work, as we
have already said, is undoubtedly the most reliable
guide for the study of the diseases of the tar in any
language, and should be in the library of every phy-
sician.— Chicago Med. Journal, July, 1860.
                    WILLIAMS  (C. J. B.i,  M.D., F. R. S.,
                Professor of Clinical Medicine in University College, London, Sec.

PRINCIPLES OF  MEDICINE.   An Elementaiy View  of the Causes, Nature,
  Treatment, Diagnosis, and Prognosis of Disease; with brief remarks on Hygienics, or the pre-
  servation of health. A new American, from the third and revised London edition.  In one octavo
  volume, extra cloth, of about 500 pages.  $3 50.  (Now Ready.)

                              WHAT TO  OBSERVE
AT  THE   BEDSIDE  AND  AFTER  DEATH,  IN   MEDICAL  CASES.
  Published under the authority of the London Society for Medical Observation.  Anew American,
  from the second and revised London edition.  In one very handsome volume, royal 12mo., extra
  cloth.  $1 00.
  To the observer who prefers accuracy to blunders 1   One of the finest aids to a young practitioner we
and precision to carelessness, this little book is in-  have ever seen.—Peninsular Journal of Medicine.
valuable.—IV. H. Journal of Medicine.          I
                            WALSHE <W. H.),  M. D.,
      Professor of the Principles and Practice of Medicine in University College, London, Sec.

A PRACTICAL  TREATISE ON DISEASES OF  THE LUNGS; including
  the Principles of Physical Diagnosis.  Third American, from the third revised and much en-
  larged London edition.  In one vol. octavo, of 468 pages extra cloth   $3 00.
  The present edition has been carefully revised and much enlarged, and may be said in the main
to be rewritten.  Descriptions of several  diseases, previously omitted, are now introduced; an
effort has been made to bring tne description of anatomical characters to the level of the wants of
the practical physician; and the diagnosis and prognosis  of each complaint are more completely
considered.  The sections on Treatment and the Appendix have, especially, been largely ex-
tended.—Author's Preface.
                                 BY THE SAME AUTHOR.

A PRACTICAL  TREATISE ON  THE DISEASES OF THE HEART AND
  PREAT VESSELS, including the Principles of Physical Diagnosis   Third American, from the
  third revised and much enlarged London edition.  In one handsome octavo volume of 420 pages,
  extra cloth.  $3 00.
  The Dresent edition has been carefully revised; much new matter has been added, and I he entire
m rk in a measure remodelled.  Numerous facts and discussions, more or less completely novel,
  ill he found in the description of tne principles of physical diagnosis; but the chief additions have
heen made in the practicul portions of the book. Several  affections, of which little or no account
had been given in the previous editions, are now treated of in detail.— Author's Preface 
30
HENRY C.  LEA'S  MEDICAL
                          New and much enlarged edition.
                       WATSON  (THOMAS),  M.D.,  Sic,
                        Late Physician to the Middlesex Hospital,  Sec.

LECTURES   ON   THE   PRINCIPLES  AND   PRACTICE  OF  PHYSIC.
  Delivered at King's  College, London.  A new American, from the  last  revised and enlarged
  English edition, with Additions, by D. Francis Condie, M. D., author of "A Practical Treatise
  on the Diseases of Children," &c.  With one hundred and eighty.five illustrations on wood.  In
  one very large and handsome volume, imperial octavo, of over 1200 closely printed pages in
  small type;  extra cloth, $6 50; strougly bound in leather, with raised bands, $7 50.
  That the high reputation of this work might be  fully maintained, the author has subjected it to a
thorough revision; every portion has been  examined with the aid of the most recent researches
in pathology, and the  results of modern  investigations in both theoretical and practical subjects
have been carefully weighed  and  embodied throughout its pages.  The watchful scrutiny of the
editor has likewise introduced whatever possesses immediate importance to the American physician
in relation to diseases  incident to our climate which are little known in England, as well as those
points in which experience here has led to different modes of practice; and he has also added largely
to the series ol illustrations, believing that in this manner valuable assistance may be conveyed to
the student in elucidating the text.  The work will, therefore, be found thoroughly on a level with
the most advanced state of medical science on both sides of the Atlantic.
  The additions which  the work has received are  shown by the fact  that notwithstanding an en-
largement in the size of the page, more than two  hundred additional pages have been  necessary
to accommodate the two large volumes of the London edition (which sells at ten dollars), within
the compass of a single volume, and in its present form it contains the matter of  at least  three
ordinary octavos.  Believing  it to be a work which should lie on the table of every  physician, and
be in the hands of every student, the publishers have put it at a price within the reach of all, making
it one of the cheapest books as yet presented to the American profession, while at the same time
the beauty of its mechanical execution renders it an exceedingly attractive volume.
  The fourth edition now appears, so carefully re-
vised, as to add considerably to the value  of a book
already acknowledged, wherever the English Ian
guage is read, to be beyond ail comparison the best
systematic work on the Principles and Practice of
Physic in the whole range of medical literature.
Every lecture contains proof of the extreme anxiety
of the author to keep pace wi th ihe advancing know-
ledge of  the day   One scarcely  knows  whether
to admire most the pure, simple, forcible English—
the vast  amount of  useful practical  infoimation
condensed into the Lectures—or the manly, kind-
hearted, unassuming  character of the lecturer shin-
ing through his work.—Land. Med. Times.

  Thus these admirable volumes come before the
profession in their fourth edition, abounding in those
distinguished attributes of moderation, judgment,
erudite cultivation, clearness, and eloquence, with
which they were from the first invested, but yet
richer than before in the results of more prolonged
observation, and  in  the able appreciation of the
latest advances in pathology and medicine by one
of the most profound  medical thinkers of the day.—
London Lancet.
  The lecturer's skill, his wisdom, his learning, are
equalled by the ease of his graceful diction, his elo-
quence, and the far higher qualities of candor, of
courtesy, of modesty, and of generous appreciation
of merit in others.—N  A  Med -Chir Review.
  Watson's  unrivalled,  perhaps  unapproachable
work on Practice—the copious additions made to
which (the fourth edition) have given it all the no-
velty and much of the interest of a new book.—
Charleston Med. Journal.
  Lecturers, practitioners, and students of medicine
will equally hail the reappearance of the work of
Dr. Watson in the form of anew—a fourth—edition.
We merely do justice to our own feelings, and, we
are sure, of the whole profession, if we thank him
for  having, in the trouble and turmoil  of a large
practice, made leisure to supply the hiatus caused
by the exhaustion of the third edition.   For Dr.
Watson has not merely caused the lectures  to  be
reprinted, but scattered through the whole  work we
find additions or alterations which prove that the
author has in every way sought to bring up his teach-
ing  to the level of the most recent acquisitions in
science.—Brit, and For. Medico-Chir.Review.
                           New and much enlarged edition.

                          WILSON (ERASMUS),  F. R. S.

A  SYSTEM  OF  HUMAN  ANATOMY, General and  Special.   A new and re-
  vised American,from the last and enlarged English Edition. Edited by W. H.Gobrecht M D
  Professor of Anatomy in the Pennsylvania Medical College, &c.  Illustrated with three hundred
  and ninety-seven engravings on wood.  In one large and handsome octavo volume, of over 600
  large pages; extra cloth, $4 00.
  The publishers trust that the well earned reputation so long enjoyed by this work will be more
than maintained by the present edition.  Besides a very thorough revision by the author it has been
most carefully examined by the editor, and the efforts of both have  been directed  to introducing
everything which increased experience in its use has suggested as desirable to render it a complete
text-book for thos-e seeking to obtain or to renew an  acquaintance  with Human Anatomy   The
amount of additions which  it has thus received may be estimated from  the fact that the Dre«ent
edition contains over one-fourth more matter than the last, rendering a smaller type and an enlarged
page requisite to keep the volume within a convenient size.  The editor has exercised the utmost
caution to obtain entire accuracy  in the text, and has largely  increased the number of illustra-
tions, of which there are about one hundred and fifty more in this edition than  in the last  thus
bringing distinctly before the eye of the student everything of interest or importance.         '
  It may be recommended to the student as no less  beauty of its mechanical execution  and the clear
                                              ness of the descriptions which it contains is equally
                                              evident.  Let students, by all  means examine tne
                                              claims of this work on their notice, before they pur-
                                              chase a text-book of the vitally important science
                                              which this volume  so fully and easily unfold..-.
                                              Lancet.                            '

                                                We ^gard it as the best system now extant for
really beautiful.  In its style the work is extremely  "tudents.— Western Lancet.
concise and intelligible.  No  one can possibly take    It therefore receives our highestcommendation —
up this volume without being struck with the great j Southern Med. and Surg. Journal.
distinguished by its accuracy and clearness of de
scription than by its typographical elegance.  The
wood-cuts are  exquisite.—Brit, and For. Medical
Review.

  An elegant edition of one of the most useful and
accurate systems of anatomical science which has
been issued from the press  The illustrations are 
AND SCIENTIFIC  PUBLICATIONS.                 31
                          WILSON  (ERASMUS),  F. R. S.

ON DISEASES  OF  THE  SKIN.  Fifth American, from the Fifth enlarged
  London edition.  In one handsome octavo volume, of nearly 700 large pages, with illustrarwns
  on wood, extra cloth   $4 50.

  This classical work, which for twenty years has occupied the position of the leading authority
in the English language on its important subject, has just received a thorough revision at the hands
of the author, and is now presented as embodying the results of the latest investigations and expe-
rience on all  matters connected with disea*-es of the skin.  The increase in the size of the work
shows the industry of the author, and his determination that it shall maintain the position which it
has acquired as thoroughly on a level with the most advanced condition of medical science.
  A few notices of the last edition are appended.
  Thewritingsof Wilson, upondiseasesof the skin,
are by far the most  scientific and practical  that
have ever been presented to the medical world on
this subject. The presentedition isa great improve-
ment on all its predecessors.  To dwell upon all the
great merits and high claims of the work before us,
seriatim, would indeed be an agreeable service; it
would  be a mental homage which we could freely
offer, but we should thus occupy an undue amount
of space in this Journal.  We will, however  look
at some of the more  salient points with which it
abounds,and which make itincomparaoiy superior to
all other treatises on the subject of dermatology  N o
mere speculative views are allowed a place in this
volume, which, without a doubt, will, for a very long
period, be acknowledged as the chief standard work
on dermatology.  The principles of an enlightened
and rational therapeia are introduced on every ap-
propriate occasion.—Am. Jour. Med Science.
  When the  first edition of  this work appeared.
about fourteen years ago, Mr Erasmus W ilson had
already given some years  to the study of Diseases
of the Skin, and he then expressed his intention of
devoting his future life to  the elucidation of this
branch of Medical  Science   In the present edition
Mr. Wilson presents us with the results of his ma-
tured experience, and we have now before us not
merely a reprint of his former publications, but an
entirely newand rewritten volume. Thus, the whole
history of the diseases affecting the skin, whether
they originate in that structure or are the mere mani-
festations of derangement  of internal  organs, is
brought under notice, and the book includes a mass
of information which is spread over a gieat part of
the domain of Medical and Surgical Pathology. We
can safely recommend  it to the  profession as the
best work on thesubjectnow in existence in the En-
glish language.—London Med. Times and Gazette.
  No matter what other treatises may be in the libra-
ry of the medical attendant, he needs the clear and
suggestive  counsels of Wilson, who  is thoroughly
posted up on  all subjects connected with cutaneous
pathology. We have, it is very true, other valuable
works on the maladies that invade  the skin; but,
compared with the volume under consideration, they
are certainly to be regarded as inferior lights in guid-
ing the j udgmeut of the medical man.—Boston Med.
and Surg. Journal, Oct. 1857.
  The author adopts a simple and entertaining style.
He strives to clear away  the complications  of his
subject, and has thus produced a book filled with a
vast  amount  of information, in a form so agreeable
as to make it pleasant reading, even to the uninitiated.
More especially does it deserve our praise because of
its beautiful and complete atlas, which the American
publishers have successfully imitated from the origi-
nal plates. We pronounce  them by far the best imi-
tations of nature  yet published  in our country. With
the text-book and atlas at hand, the diagnosis is ren-
dered easy and accurate, and  the practitioner feels
himself safe in his treatment.   We will add that this
work, although it must have been very expensive to
the pulTlishers, is not high  priced. There is  no rea-
son, then, to prevent every physician from obtaining
a work of such importance, and one which will save
him both labor and perplexity.— Va. Med. Journal.
  As a practical guide to the classification, diagnosis,
and treatment of the diseases of the skin, the book is
complete.  We know nothing, considered in this as-
pect, better in our language; it is a safe authority oh
all the ordinary  matters which, in this range of dis-
eases, engage the practitioner's attention, and pos-
sesses the  high  quality — unknown, we believe, to
every older manual, of being on a level with science's
high-water mark; a sound book of practice.—London
Med. Tiroes.
                                     ALSO, NOW READY,

A  SERIES OF PLATES  ILLUSTRATING  WILSON  ON  DISEASES  OF
  THE SKIN; consisting of twenty beautifully executed plates, of which thirteen are exquisitely
  colored, presenting the Normal Anatomy and Pathology of the Skin, and containing accurate re-
  presentations of about one hundred varieties of disease, most of them the size of nature.  Price
  in cloth.  $5 50.
  In beauty of drawing and accuracy and  finish of coloring these plates will  be found equal to
anything of the kind as yet issued in this country.  The value of  the new edition is enhanced by
an additional colored plate.
  The plates by which this edition is accompanied
leave nothing to be desired, so far as excellence of
delineation and perfect accuracy of illustration are
concerned.—Medico-Chirurgical Review.
  Of these plates it is impossible to speak too highly.
The representations of the various forms of cutane-
ous disease are singularly accurate, and  the color-
ing exceeds almost anything we have met with.—
British and  Foreign Medical Review.
  We ha7e already expressed our high appreciation
of Mr. Wilson's treatise on Diseases of the Skit.
The  plates  are  comprised  in" a  separate volume,
which we counsel all those who possess the text to
purchase.  It is a beautiful specimen of color print-
ing, and the representations of the various forms of
skin disease are as faithful as is possible in plates
of the size.—Boston Med. and Surg. Journal, April
9, 1858.
  Also, the TEXT  and PLATES done up in one hands >me volume, extra cloth, price $9 50.

                                    BY THE SAME AUTHOR.

THE  DISSECTOR'S  MANUAL;  or,  Practical and  Surgical Anatomy.   Third
  American, from the last revised and enlarged English edition.  Modified and rearranged, by
  William Hunt, M. D., Demonstrator of Anatomy in the University ol  Pennsylvania.  In one
  large and handsome royal 12mo. volume, ext.acloth. of 582 pages, with 154illustrations.  $2 00.

                                   BY THE SAME  AUTHOR.

HEALTHY  SKIN;  A Popular Treatise on the  Skin and Hair, their  Preserva-
  tion and  Management.   Second American, from the fourth London edition.  One neat volume,
  royal 12mo., extra cloth, of about 300 pages, with numerous illustrations. $1 00. 
32
HENRY  C.  LEA'S MEDICAL PUBLICATIONS.
                 WINSLOW (FORBES),  M.D.,  D. C.L.,  Sec.

ON OBSCURE DISEASES OF THE BRAIN AND DISORDERS OF  THE
  MIND; their incipient Symptoms, Pathology, Diagnosis, Treatment, and Prophylaxis.  Second
  Arwrican,  from the third  and revised English edition.  In one handsome octavo volume, of
  nearly 600 pages, extra cloth.  $4 25.  (Just Ready)
  We close this brief and necessarily very imperfect Pathology.  It completely exhausts the subject, in
notice of Dr. Winslow's fercat and classical work,
by expressing our conviction that it is long since so
import:int and beautifully written a volume has is-
sued from the British medical press.—Dublin Med.
Press, July 25, lfctfO.
  We honestly believe this to be the best book of the
season.— banking's Abstract, July, 1860.
  The 'after portion of Dr. Winslow's work is ex-
clusively devoted to the consideration of Cerebral
the same manner as the previous seventeen chapters
relating to morbid psyuhical phenomena left nothing
unnoticed in reference to the mental symptoms pre-
monitory  of cerebral disease   ft is impossible to
overrate the benefits likely to result from a general
perusal of Dr. Winslow's valuable and  deeply in-
teresting work.—London Lancet, June 23, 1860.

  It contains an immense  mass of information.—
Brit, and  For. Med.-Chir. Review, Oct. I860.
                            WEST  (CHARLES),  M. D.,
Accoucheur to and Lecturer on Midwifery at St. Bartholomew's Hospital, Physician to the Hospital for
                                    Sick Children, Sec.

LECTURES  ON  THE  DISEASES OF WOMEN.   Second American, from the
  second London edition.  In one  handsome octavo volume, extra cloth, of about 500 pages;
  price $3 25.
*** Gentlemen who received the first portion, as issued in the " Medical News and Library," can
  now complete their copies by procuring Part II, being page 309 to end, with Index, Title matter,
  tec, 8vo., cloth, price $1 25.
  We must now conclude this hastily written sketch
with the confident assurance to our readers that the
work will well repay perusal.   The conscientious,
painstaking, practical physician isapparent on every
page.—N. Y. Journal of Medicine.
  We know of no treatise of the kind so  complete
and yet so compact.—Chicago Med. Jour.

  A fairer, more honest, more earnest, and more re-
liable investigator of the many diseases of women
and children is not to  be found in any country.—
Southern Med. and Surg. Journal.

  We have to say of it, briefly and decidedly, that
it is the best work  on the subject in any language;
and that it stamps Dr. West as the facile princepi
of British obstetric authors.—Edinb. Med. Journ.
  We gladly recommend his Lectures as in the high-
est degree instructive to all who are interested in
obstetric practice.—London Lancet.
  Happy in his simplicity of manner, and moderate
in his expression of opinion, the author is a sound
reasoner and a good  practitioner, and his book is
worthy of the handsome garb  in which it has ap-
peared.— Virginia Med. Journal.

  We must take leave of Dr. West's very useful
work, with our commendation  of the clearness of
its style, and the inoustry and sobriety of judgment
of which ii gives evidence.—London Med  Times.

  Sound judgment and good sense  pervade every
chapter of the oook.  From its perusal we have de-
rived unmixed satisfaction.—Dublin Quart. Journ.
                           BY THE same AUTHOR.  (Just Ready.)

LECTURES  ON  THE  DISEASES  OF INFANCY AND  CHILDHOOD.
  Fourth American, from the fifth enlarged and  improved  London edition.   In one handsome
  octavo volume, extra cloth, of about six hundred and fifty pages.  $4 50.
  The numerous editions throuerh which this work  has passed on both sides of the Atlantic are
the best evidence that it  has met a want felt by the profession.   Few practitioners, indeed  have
had the  opportunities of observation and experience enjoyed by the author.   In his Preface  he
remarks: -The present  edition embodies the results of 1200 recorded  cases, and of nearly 400
post-mortem examinations, collected from between 30,000 and 40,010 children, who, during the past
twenty -six years have come  under my care, either in public or in private practice."  The universal
favor with which the work has been received shows that the author has made  good use of these
unusual advantages.

  The three former editions of the work now before
us have placed the author in the foremost rank of
those physicians who havecevoted special attention
to the diseases of early life  We attempt no ana-
1> sis of this edition, but may refer the reader to some
of the chapters to which the largest additions have
been made—those on Diphtheria, Disorders of the
Mind, and Idiocy, for instance—as a prooi that the
work is really a  new edition j not a mere  reprint.
In its preient shape, it will  be tound of the greatest
possible service  in the every-day practice of nine-
tenths of the profession.—Med. Times and Gazette,
London, Dec. 10, 1859.
  All things considered this book of Dr. West is
by far the lest treatise in our  language upon such
modifications of morbid action and disease as are
wiintssed when we have to deal «vith infancy and
childhood".  It is true that it confines itself to such
disorders as come within the province of the phy-
sician, and even with respect to these it is unequal
as regards minuiemss of consideration,  and some
diseases it omits to notice altogether.  But those
who know anything  of the present  condition  of
paediatrics will readily admit that it would be next
to impossible to effect more  or effect it better, than
the accoucheur of St. Bartholomew's has done in a
single volume.  The lecture (XVI.) upon Disorctrs
of the Mind in chilaren is an admirable specimen of
the value oi the later  information convened in  trii

Octt22:818059Dr- Charle8 W™--LoZoTLanlce?,

  Since the appearance of the first edition, about
eleven years ago, the experience of  the author has
doubled; so that, whereas the lectures at first were
founded on six hundred observations, and one hun-
dred and eigniy dissections madeamong nearly four-
teen thousand children, they now embody the resuU.
of nine hundred observations, and two hundred and
eigby-eight post-mortem examinations made amon.
nearly thirty thousand ch.ldren, who, during  n!
£VrM*J Y,Wn> have been  «nder'hi. cafe _
British Med. Journal, Oct. 1, 1859.
BY THE SAME AUTHOR.
AN  ENQUIRY INTO THE PATHOLOGICAL  IMPORTANCE OF ULCER.
  ATION Or  THE OS  UTERI.  In one neat octavo volume, extra cloth.  $1 25. 
 
.-•I..-'. -'.',
.i*in-Mr.
'■\Jvm
•'<'■■  "■'. ■ ■•'■
1


   :

.-■•■' '.V:>.'W;.;.y,:;.
'"   V'- ^. fi
' * i-,v^
 X ,.  '■:.  ' X?XX;:\.Xi   XX--.,,*-A'     -*#r

•I _..,-■'.  . ;'Xr; ,'4 «'•■<■'--u  '•:.', ' X  -X   ,*'f':X

hi ?-' :'  -!'    K»  ■■■■  ..',''''' ,0  : .'4i • •&$&










             ,     --X   ,          ',
XXX^irXy
,!;:;."*'.!
\;J^S$$
v,.-i;wl#.
':'■> :',i.;l',;iV.''Vi


'■'.^'•!'■':':'■ %•'''''
   >>ii..l/*t:#;':




■'      .      P.
i »
w^mfi
*'4*